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1.
2022 PHYSIOTHERAPY COMPETENCY EXAM
(PCE) WRITTEN COMPONENT APPLICATION FORM
COMPLETE ALL FIELDS
Please type or print clearly
Please check () one First application
2.
PIN (If you have previously registered with, or are currently registered with, CAPR, please provide your PIN)
3.
Please check () one Ms. Mr. Mx.
4.
A) NAME (As shown on your piece of Government issued photo ID) 4. B) Date of birth / /
Year Month
Day
Surname
First Name(s) Middle Name
5.
Email address (REQUIRED)
6.
ADDRESS (all mail, including your exam results, will be mailed to this address)
Apt # Street (number and name)
Street (number and name) continued City
Country Province
Canadian postal code
Postal code/zip code Telephone (preferred number to be reached at)
(if country other than Canada)
7.
PHYSIOTHERAPY EDUCATION (List all post-secondary education)
Name of institution
City/Country
Dates (from/to)
Graduation year
Name of degree/certificate
8.
If you obtained your entry-level physiotherapy education outside Canada, has CAPR assessed your educational credentials and
qualifications? Yes No (The Credentialling Department will forward a copy of your Final Results Letter to the Exam Department)
9.
CHOICE OF LANGUAGE FOR EXAM English French
Re-examination Last exam date
Attach Photo Here
(Paper-clip ONLY, DO NOT
GLUE)
Refer to 'Candidate
Identification' in Policy Guide
for Photo Information
Photo MUST be signed and
dated on the back.
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Money Order / Certified Cheque OR
Credit card (Debit credit cards are not accepted)
Card type (check one):
Expiry (mmyy):
Cardholder’s name (as it appears on the card):
Cardholder’s signature:
10.
PLEASE SELECT YOUR EXAM DATE:
11.
WRITTEN COMPONENT MODALITY Test Centre (complete site preferences below) Remote Proctoring
Please rank your top three site preferences. While these are the probable Written Component exam sites, please note that CAPR
reserves the right to run additional sites based on registration numbers.
Province
Site Choices
Province
Site Choices
Alberta
Calgary
Edmonton
Nova Scotia
Halifax
British Columbia
Abbotsford
Vancouver
Victoria
Ontario
Hamilton
Kingston
London
Ottawa
Sudbury
Thunder Bay
Timmins
Toronto
Whitby
Windsor
Manitoba
Winnipeg
Prince Edward Island
Charlottetown
New Brunswick
Fredericton
Moncton
Saint John
Quebec
Montreal
Newfoundland &
Labrador
St. John’s
Saskatchewan
Regina
Saskatoon
12.
Do You Require Alternative Accommodations? Y
es
No
If yes,
you must send additional information with your application. See the Exam Policies for details.
13.
METHOD OF PAYMENT Please see Exam Registration Guide for payment options.
I authorize the Canadian Alliance of Physiotherapy Regulators to charge C$1,022.00 to my credit card:
Card number :
CVC2 Code (3 digit number on the back of the card):
Exam Date
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14.
LIMITS OF CAPR’S LIABILITY
Before you register for the Physiotherapy Competency Examination (PCE), you must read and understand the limits of liability. You must tell
interested parties, such as potential or current employers, about the limits of liability. While the Canadian Alliance of Physiotherapy Regulators
(CAPR) takes reasonable steps to ensure the accuracy and completeness of information, resources and reports, neither CAPR nor any of its
officers, employees or agents shall be responsible for damages or losses in the event of any errors or omissions, or liable for any damages or
losses incurred by a candidate, an employer or a contractor as a result of any decision made by or on behalf of CAPR or any of its officers,
employees or agents. This means that CAPR is not responsible for impacts of a personal, professional or financial nature. This includes such
impacts as loss of income, loss of salary, and expenses incurred by an employer, a contractor or a candidate.
By registering for and participating in the PCE, you agree that you will take no legal action or other proceedings against CAPR or any of its
officers, employees or agents for anything done in good faith related to the PCE, including any errors, omissions, neglect or default. You also
agree to fully release and indemnify CAPR, its officers, employees and agents for any such actions or proceedings. This means that CAPR will
not be responsible for any loss of income or other expenses incurred by you or an employer or contractor due to a decision made by CAPR
related to the PCE, and that you agree not to take legal action against CAPR.
15.
DECLARATION
I have read and understood the information in the Exam Policies and the Exam Registration Guide; including the refund process, appeal policy, limits
of liability and the contents and spirit of the Rules of Conduct for the PCE. I have read and understood CAPR’s Privacy Policy and I consent to the
collection, use and disclosure of my personal information for the purposes described in CAPR’s Privacy Policy.
I authorize the disclosure of my exam status and results to Canadian physiotherapy regulatory agencies. I understand that eligibility for the Clinical
Component of the PCE is subject to my successful completion of the Written Component. I understand that I can be disqualified from taking or
continuing to sit for the administration of the examination if I fail to comply with any term or condition in the Exam Policies. I declare that all
information on this form and any accompanying documents is true, correct and complete.
I am aware that CAPR may need to verify the information provided, and therefore CAPR may need to disclose my information to third parties. I
consent to such disclosure. I also consent to third parties disclosing my personal information to CAPR, so that CAPR can process my application
and verify the information I have provided. I authorize the disclosure of non-identifying data for research purposes.
Signature (REQUIRED): Date:
An electronic signature is not accepted.
In addition to the above, I authorize the disclosure of my examination results and Candidate Score Report to my Canadian physiotherapy program
or Canadian Bridging Program for purposes of internal program evaluation and review.
Signature (OPTIONAL): Date:
An electronic signature is not accepted.
CHECKLIST FOR WRITTEN COMPONENT APPLICATION:
Complete, sign, and date the Application Form.
Include all payments.
Include one passport sized photograph of yourself. (IMPORTANT: ONLY if you have not already submitted this OR your current photo is 5 years or older OR your official name has
changed or your feel your appearance has changed drastically. Please make sure you sign & date your photo)
Include additional documents, if needed (information about special needs, please refer to the Policy Guide)
Include additional documents, if needed (information about special accommodations).