Protected B
once completed
PIB PE-808
Page 1 of 1RCMP GRC ED6222e (2019-03)
Medical Information Reference
BC RCMP 9-1-1 Police Dispatcher
Date (yyyy-mm-dd)
Candidate Information
HRMIS No. Candidate Surname Candidate Given Name Applicant ID
Primary Personal Physician's Information
Physician Surname Physician Given Name Telephone Number
Address City Province Postal Code (A9A 9A9) Fax Number
Information of Additional Physicians Consulted Within the Past Three (3) Years
Physician 1
Physician Surname Physician Given Name Specialty Telephone Number
Address City Province Postal Code (A9A 9A9) Fax Number
Use the back of the form if more space is required.
Physician 2
Physician Surname Physician Given Name Specialty Telephone Number
Address City Province Postal Code (A9A 9A9) Fax Number
Physician 3
Physician Surname Physician Given Name Specialty Telephone Number
Address City Province Postal Code (A9A 9A9) Fax Number
Declaration
I declare that the information contained in this Medical Information Reference is true and accurate to the best of my knowledge.
Candidate Surname Candidate Given Name
Date (yyyy-mm-dd)Signature
Submission Instructions
Once completed, please return this form to your Recruiter in a sealed envelope.
Filing Instructions
Completed Form to be filed in the Medical Folder, held in E Division Occupational Health Services Section, 530 OCC Applicants.
