Membership Application Form

Personal Information

Given Name*

Middle Initial

Surname*

Maiden Name

Street Address*

City*

Province*

Country*

Postal Code

Phone*

Fax

Email*

Date Of Birth*

Sex*

Female
Male

Are you seeking registration with NBASLPA to practice in NB?*

Yes
No

Employment start date

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

Citizenship

Are 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

Education

If 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/Diploma	Area of Concentration	Institution	Year

Please enter your information above. Click the PLUS sign to add additional Degrees/Diplomas.

Registration/Licensure/Certification

Are 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

Regulatory Body/ Professional Association	Province/State/Country	Registration/License/ Certification No.	Expiry Date

Please enter your information above. Click the PLUS sign to add additional Degrees/Diplomas.

Professional Experience

Do you have any professional experience?*

Yes
No

Employer	Position Held	Address	Period of Employment

Please enter your information above. Click the PLUS sign to add additional experience.

File Uploads

Upload Supporting Documents*

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 2 MB.

Master’s Degree Diploma*

Accepted file types: jpg, png, pdf, Max. file size: 2 MB.

Letter of good standing from your current provincial association (home jurisdiction).

Accepted file types: jpg, png, pdf, Max. file size: 2 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.