APPLICATION FOR LICENSE FORM

Transcription

1 APPLICATION FOR LICENSE FORM Staple your two passport photos here. Sign the back of each photo. FOR: - Internationally educated professionals - Graduates of non-accredited Canadian programs - Graduates of accredited Canadian programs I am applying to become licensed as a: License# Licensed Optician Eyeglass Dispensing Contact Lens Licensed Optician Checklist: FOR OFFICIAL USE ONLY On Register Criminal Record Search Certificate 2 Passport Photos (verified) License Fees /Payment Proof of Insurance OAC Other OAC Membership&Insurance Application 1. CONTACT INFORMATION A. Personal Given Name: Surname: Address: City/Town: Province/State: Country: Postal Code: Telephone: Gender: Male Female Date of Birth: / / (Month/Day/Year) B. Business Business Name/ Employer: Address: City/Town: Province/State: Country: Postal Code: Telephone: Fax: Are you the owner of the above business? Yes No Send mail to (check one): Personal address Business address Application for Registration Form 1 OpticiansOfManitoba.ca

2 C. Information Release Under the Privacy Information Act, the only information on this form that can be released is your Business information. Personal contact information can only be released with your approval. Please sign one of the following lines: Release business contact information only: Release all contact information: REQUIRED DOCUMENTS A. OAC Membership (Optional) See 4. Payment Agreement Membership The benefits of membership include one million dollars in Personal Professional Errors&Ommissions Liability Insurance, online Maintenance of Competency modules and advocacy. If you wish to apply for membership: Complete the OAC Membership Form and submit to OOM. For details visit opticians.ca Additional Professional Liability Insurance You can purchase additional Professional Liability Insurance if you wish. Check the OAC website for rates. If you wish to apply for additional Professional Liability Insurance through OAC: Identify your insurance purchase on the OAC Membership Form with payment details. OOM will accept your OAC Membership Form and Liability Insurance fee as proof of insurance. CL Spectrum Magazine If you wish to subscribe to CL Spectrum Magazine through OAC : Identify your subscription on the OAC Membership Form with payment details. Submit all the above documents to OOM. Do NOT submit the above documents to OAC. Complete the payment authorization section of the OAC membership Form. Application for Registration Form 2 OpticiansOfManitoba.ca

3 B. Proof of Insurance You require a minimum of $1 million in Personal Professional Errors&Ommission Liability Insurance coverage. OOM will accept your complete OAC Membership Form with payment details as proof of insurance. Provide a photocopy of your of your insurance coverage if you are purchasing the insurance from someone other than the OAC. If you are acquiring insurance from Opticians Association of Canada (OAC) see above (2A. Membership & Liability Insurance) for details on Proof of Insurance. C. Criminal Record Search Certificate You require a Criminal Record Check through the Winnipeg Police Service or your local Police Station. Provide your original Criminal Record Search Certificate to OOM unless you have done so within the past 5 years. OOM will accept an original Criminal Record Search Certificate that is up to five years old. Photocopies will NOT be accepted. A Vulnerable Sector Screening is NOT required. D. Passport Photos Provide two original/ recent passport photos with your signature on the back of each photo unless you have done so within the past five years. Staple the photos to the top right of this application form (page1). 3. LICENSE FEE Pay your License fee for Eyeglasses or Contact Lenses. See OpticiansofManitoba.ca for current fees PAYMENT AGREEMENT Attached is the sum of $. The above sum includes: for my Opticians of Manitoba License fee for Eyeglasses Contact Lenses. (if applicable) for my Opticians Association of Canada (OAC) membership fee. (if applicable) for my additional Liability Insurance through OAC (If applicable) for my CL Spectrum Magazine Subscription through OAC In the event that this application is not accepted due to a suspension or other reason in keeping with the applicable Acts of Manitoba, OOM bylaws, regulations, Code of Ethics and Standards of Practice it is understood that said monies will be promptly refunded. Application for Registration Form 3 OpticiansOfManitoba.ca

4 Payment Type My payment is made by: Money order Personal Certified cheque/ Company cheque (Please make payable to (OPTICIANS OF MANITOBA) Credit card (To pay by telephone, call ) Credit Card Authorization Visa MasterCard I authorized the Opticians of Manitoba to charge my credit card in the amount of $. Credit card number Expirydate / Namecardholder Signature of cardholder 5. DECLARATION This must be signed. You must also complete and sign appendix A if you are active and B if you are inactive. I do solemnly swear that: A. I have completed the application to the best of my knowledge and believe the completed form is correct and true. I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath and by virtue of the Canada Evidence Act. B. My entitlement to practise as a Licensed Optician or Contact Lens Licensed Opticians has not been limited, restricted or subject to conditions in any jurisdiction which could result in the suspension or cancellation of my authorization to practice as same in that jurisdiction. C. I, having read the applicable Acts of Manitoba, OOM bylaws, regulations, code of ethics, and standards of practice in force pursuant thereto, do declare that I will uphold the honour and dignity of the profession and adhere to the above in force pursuant thereto. Dated at the city of in the province of, this day of the month of in the year 20. Signature: Please print your name as you want it to appear on your Licence. Application for Registration Form 4 OpticiansOfManitoba.ca

5 6. DELIVERY Mail or hand-deliver the Application for Licence forms with all required documents and fees to: Registrar, Opticians of Manitoba Garry Street Winnipeg, Manitoba Canada R3C 4J9 Phone: Application CANNOT be faxed or ed. Original signatures are required. Application for Registration Form 5 OpticiansOfManitoba.ca