Membership Application Personal InformationGiven Name*Middle InitialSurname*Maiden NameStreet Address*City*Province*New BrunswickAlbertaBritish ColumbiaManitobaNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonCountry*CanadaUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwePostal CodePhone*FaxEmail* Date Of Birth* Date Format: MM slash DD slash YYYY Sex*FemaleMaleAre you seeking registration with NBASLPA to practice in NB?*YesNoEmployment start date Date Format: MM slash DD slash YYYY Have you previously applied for registration with NBASLPA?YesNoHave you previously been issued a registration number by NBASLPA?YesNoProfession*Speech-Language-PathologistAudiologistCitizenshipAre you a Canadian Citizen?*YesNoAre you a permanent resident/landed immigrant of Canada?*YesNoDo you have employment authorization under the Immigrant Act?*YesNoEducationIf you completed your education and training program outside of North America, NBASLPA requires that your qualifications be assessed to determine their equivalence with the Canadian standards of a Master's degree. Please refer to the list of agencies available for you to contact to complete the required academic qualifications assessment.Degree/DiplomaArea of ConcentrationInstitutionYear Please enter your information above. Click the PLUS sign to add additional Degrees/Diplomas.Registration/Licensure/CertificationAre you currently or have you been registered/licensed/certified to practice as an audiologist and/or speech-language pathologist in other provinces/states/countries?*YesNoRegulatory Body/ Professional AssociationProvince/State/CountryRegistration/License/ Certification No.Expiry Date Please enter your information above. Click the PLUS sign to add additional Degrees/Diplomas.Professional ExperienceDo you have any professional experience?*YesNoEmployerPosition HeldAddressPeriod of Employment Please enter your information above. Click the PLUS sign to add additional experience.File UploadsUpload Supporting Documents* Drop files here or Accepted file types: jpg, png, pdf. Master’s Degree Diploma*Accepted file types: jpg, png, pdf.Letter of good standing from your current provincial association (home jurisdiction).Accepted file types: jpg, png, pdf.This letter is required for all applicants eligible for registration through the inter-provincial labour mobility agreement.Declaration* I authorize NBASLPA to obtain information from other regulatory bodies, professional associations, educational institutions, and/or present and former employers for purposes related to my registration and qualifications. □ I have not been convicted of any criminal offences or offences related to the regulation of the practice of audiology and/or speech-language pathology.oice I have not been convicted of any criminal offences or offences related to the regulation of the practice of audiology and/or speech-language pathology. I have not been the subject of a finding of professional misconduct, incompetence, or incapacity in relation to audiology and/or speech-language pathology, or another regulated profession. I certify that the statements made by me on this application form are complete and accurate. I understand that false or misleading information may be cause for revocation of my certificate of registration or other disciplinary action.