Fillable B ridging Program for Ultrasound orm Application F (The Michener Institute of Education at UHN)

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B ridging Program for Ultrasound orm Application F (The Michener Institute of Education at UHN)

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B
ridging Program for Ultrasound
Application F
orm
Tel: 416.596.3101 ext. 3178 or 3147
Email: bridging@michener.ca
Date Received
Office Use Only
Fill in the requested information by keyboard, then PRINT and SIGN the form.
PERSONAL INFORMATION
LAST NAME
FIRST NAME
MIDDLE NAME
STUDENT ID # (former Michener students)
DATE OF BIRTH (MM/DD/YYYY)
________ /________ /___________
GENDER: [ ] Female [ ] Male [ ] Other
COUNTRY OF CITIZENSHIPSHIP
[ ] Canadian [ ] Other _________________________________
LANGUAGE (FIRST)
[ ] English [ ] French [ ] Other: ______________________
STATUS IN CANADA
[ ] International Student
[ ] International Student with Study Permit
[ ] Permanent Resident
[
] Protected Person/Refugee
PROFESSIONAL INFORMATION
I am internationally educated and have experience in the following area:
COUNTRY WHERE TRAINED/EXPERIENCED
YEARS OF EXPERIENCE
CONTACT INFORMATION
ADDRESS CITY OR TOWN PROVINCE
POSTAL CODE TELEPHONE
(_______) ___________ -__________________
EMAIL ADDRESS (required)
PROGRAM SELECTION
BPUS800 - Bridging Program for Ultrasound
SUPPORTING DOCUMENTATION:
The following supporting documentation is also required with your application:
Proof of minimum 2 years of sonography experience
Proof of Formal Diagnostic Ultrasound Education. Copy of graduation diploma, degree, certificate or other proof of credential)
Detailed resume outlining your diagnostic ultrasound education and work experience
Appl
icants for whom English is a second language must provide English Language Assessmen
t (valid within 2 years).
Review our English Language Policy for exemptions.
AUTHORIZATION AND DECLARATION
I understand that if any information in my application is determined to be false or misleading, concealed or withheld, my application may be invalidated and this could
result in its immediate rejection or in the revocation of an offer of admission or registration at The Michener Institute of Education at UHN. I, the undersigned, declare
that all application information and all supporting documentation are truthful, complete and correct.
Applicant Signature
: ________________________________________________________
Date
_______________________
PLEASE SUBMIT YOUR APPLICATION AND SUPPORTING DOCUMENTS TO: bridging@michener.ca
The information on this form is collected under the authority of the Michener Institute of Education at UHN and will be protected and used in compliance
with the Ontario Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F.31. Student information held by the Michener Institute of
Education at UHN may be used for administrative and statistical purposes of the Institute and/or the ministries and agencies of the Government of Ontario
and the Government of Canada.
Bridging Program for Ultrasound- Application Form 2019-02-01
Office Use Only
Date Received
[ ] Canadian Citizen
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B ridging Program for Ultrasound orm Application F (The Michener Institute of Education at UHN)

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Completed 10 February 2021

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