Membership Application Personal InformationGiven Name* Middle Initial Surname* Maiden Name Street 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 Code Phone*FaxEmail* Date Of Birth* MM slash DD slash YYYY Sex* Female Male Are you seeking registration with NBASLPA to practice in NB?* Yes No Employment start date MM slash DD slash YYYY Have you previously applied for registration with NBASLPA? Yes No Have you previously been issued a registration number by NBASLPA? Yes No Profession* Speech-Language-Pathologist Audiologist CitizenshipAre you a Canadian Citizen?* Yes No Are you a permanent resident/landed immigrant of Canada?* Yes No Do you have employment authorization under the Immigrant Act?* Yes No EducationIf 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.Please enter your information above. Click the PLUS sign to add additional Degrees/Diplomas.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?* Yes No Please enter your information above. Click the PLUS sign to add additional Degrees/Diplomas.Regulatory 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?* Yes No Please enter your information above. Click the PLUS sign to add additional experience.EmployerPosition HeldAddressPeriod of Employment Please enter your information above. Click the PLUS sign to add additional experience.File UploadsUpload Supporting Documents* Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 64 MB. Master’s Degree Diploma*Accepted file types: jpg, png, pdf, Max. file size: 64 MB.Letter of good standing from your current provincial association (home jurisdiction).Accepted file types: jpg, png, pdf, Max. file size: 64 MB.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.