Optician Registration Application Form (Page 7 of 10) in pdf

Optician Registration Application Form Page 7

SECTION 8 FEES

Combined Application & Annual Registration Fee for 2016 (includes HST):

January 1

- March 31st (100%)

$1160.51

April 1

- June 30th (75%)

$912.76

July 1

- September 30th (50%)

$665.01

October 1

- December 31st (25%)

$417.25

Visa

MasterCard

Method of Payment: (select payment method)

Credit Card Number

Expiry Date (mm/yy)

Cardholder’s Name

Cardholder’s Signature

SECTION 9 AUTHORIZATION AND DECLARATION

(print your name) herby apply for registration as a Registered Opticin and certify that the

statements made by me on this application are complete and correct to the best of my knowledge and belief. I understand that a false or misleading statement may

result in professional misconduct proceedings being brought against me, may disqualify me from registration or may be cause for revocation of any registration

which may be granted to me . I understand that my registration fee will be processed upon receipt but that this does not imply that my application has been

approved. Upon approval of my application my registration approval documents will be sent to me. I confirm that the photos I have submitted are a true likeness of

me.

I understand that, in accordance with article 15 of the College of Opticians of Ontario’s (the “College’s”) By-laws, should I provide my home address as my place of

business or as my “designated address”, my home address will be made publicly available on the College’s Public Register. Should I feel that this would jeopardize

my personal safety, I understand that I need to make a request, in writing, to the Registrar to have this information removed from the Public Register. I also

understand that it is a requirement of the Opticianry Act and its regulations that I notify the College, in writing, of any change in my legal name, home or

business information within thirty (30) days of the change.

Signature:

Date:

mm//dd//yyyy

Witness Name:

Witness Signature:

Please print clearly

Signed at:

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