Application for Registration Renewal 2014 2015

Application for Registration Renewal 2014 2015 APPLICATION FOR REGISTRATION RENEWAL 2014 2015 This Application for Registration Renewal ( Renewal Form ) must be completed and returned with payment to the College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario ( CTCMPAO ) ON OR BEFORE JUNE 1, 2014. Members can renew online or by mail and can pay by certified cheque or money order. If your Renewal Form is not received by CTCMPAO by the end of the day on June 1, 2014, your registration may be suspended for non payment of fees and you will not be legally entitled to practise in Ontario in 2014 2015. Ensure that you have completed all sections of the Renewal Form. Your renewal fees must be included with your form. No sections may be left unanswered unless otherwise indicated. This will help you avoid a potential late fee if your Renewal Form is received incomplete on or after June 1, 2014. The completion and signing of this Renewal Form has legal consequences. Any false or misleading statements could be considered to be acts of professional misconduct and may lead to discipline and/or other proceedings. If you have any questions regarding the completion of this Renewal Form, please consult CTCMPAO s Registration Renewal Guide (available on our website at www.ctcmpao.on.ca) or contact Entry to Practice staff at registration@ctcmpao.on.ca. 1. Member Name Indicate your name on the CTCMPAO public register: Mr. Ms. First Name: Middle Name (if applicable): Last Name: Change in Name I have changed my legal name since registration/last registration renewal, and I am submitting a written request with evidence of my name change with the Renewal Form. (NOTE: Changes in name cannot be done online. Proof of name change must be submitted by mail.) 2. Class, Title/Designation and Registration Number Class of Certificate Indicate your current class of certificate: General Grandparented FOR OFFICE USE ONLY Registration No.: Date Renewal Form Received: Date Payment Received: Data Entry Date: 1 P age

Title(s)/Designation(s) and Registration Number Indicate your current title(s)/designation(s): Traditional Chinese Medicine Practitioner (R.TCMP) Acupuncturist (R.Ac) Provisional Traditional Chinese Medicine Practitioner (R.TCMP [Provisional]) Provisional Acupuncturist (R. Ac [Provisional]) Registration Number: Status Change (if applicable) If you wish to change your registration status, indicate below: I wish to resign from CTCMPAO (skip to the Notice of Resignation). I wish to apply for Inactive class of membership (skip to the Notice of Inactive class). 3. Current Home Address Street No. & Name (Required) Suite No. City (Required) Province (Required) Country (Required) Postal Code (Required) Telephone (Required) Ext. Fax Email (Required) Preferred Mailing Address: Home Address Primary Business Address Second Business Address Preferred Telephone Number: Preferred Email Address: 4. Language Fluency Languages in which you can speak, read and write with reasonable fluency: English French I cannot speak, read and write with reasonable fluency in either English or French and I am a Grandparented member currently practising with a written language plan approved by the Panel of the Registration Committee. ADDITIONAL LANGUAGES Additional languages in which you can personally and competently provide professional services (up to 4): 1. 2. 3. 4. I agree to allow information regarding my ability to personally and competently provide professional services in the above noted additional languages to be disclosed on the public register: 2 P age

5. Annual Declaration of Business / Practice Hours [For Information Only] Sections 7 and 10 of CTCMPAO s Registration Regulation states that by the end of the third year after becoming a member, any member who, in the preceding three (3) years, has conducted fewer than 500 traditional Chinese medicine ( TCM ) and/or traditional Chinese acupuncture patient visits in which TCM diagnosis was utilized will be referred to the Quality Assurance Committee for a peer and practice review. NOTE: In two (2) years CTCMPAO will begin asking members the following question on their 2016 Renewal Form. You do not need to answer this question on this year s form. Have you conducted 500 or more TCM and/or traditional Chinese acupuncture patient visits in which TCM diagnosis was utilized in the past three years (i.e. Since April 1, 2013)? OR Have you successfully completed a refresher course approved by the Registration Committee within the last twelve months? 6. Quality Assurance Quality Assurance Program Compliance I have complied with the annual requirements of CTCMPAO s Quality Assurance Program. I have NOT complied with the annual requirements of CTCMPAO s Quality Assurance Program. Attach a detailed explanation to your Renewal Form. 7. Concurrent Registration Check off any and all other regulatory colleges/bodies in Ontario for which you hold a current certificate of registration and attach verification of your registration/licensure: College of Chiropodists Association of Certified Engineering Technicians and College of Chiropractors Technologists College of Dental Hygienists College of Early Childhood Educators College of Dental Technologists Professional Engineers Royal College of Dentist Surgeons Professional Foresters Association College of Denturists Certified General Accountants College of Dietitians Association of Professional Geoscientists College of Kinesiologists Association of Land Surveyors College of Massage Therapists Law Society of Upper Canada College of Medical Laboratory Technologists Certified Management Accountants College of Audiologists and Speech Language Pathologists College of Social Workers and Social Service Workers College of Medical Radiation Technologists College of Teachers College of Midwives College of Trades College of Nurses College of Veterinarians College of Occupational Therapists Other: College of Opticians College of Optometrists College of Pharmacists College of Physicians and Surgeons College of Physiotherapists College of Psychologists College of Respiratory Therapists Association of Architects Institute of Chartered Accountants 3 P age

8. Current Business / Practice Information In accordance with the Health Professions Procedural Code, each member s name, PRIMARY business address and PRIMARY business telephone number will appear on CTCMPAO s public register. Facility Name Street No. & Name (Required) Suite No. City (Required) Province (Required) Country (Required) Postal Code (Required) Website Telephone (Required) Ext. Fax The information collected in the following section is data that all health regulatory colleges are required to collect and report annually to the Ministry of Health and Long Term Care. A. BUSINESS / PRACTICE INFORMATION Members are required to provide details about ALL current business locations. Primary Business What is your employment relationship at your Primary Business? Check only one. Permanent (indeterminate duration of employment and guaranteed or fixed practice hours per week) Temporary (fixed duration of employment, based on a defined start date and end date) Casual (on an as needed basis) Self employed (a person who operates his or her own enterprise in the TCM and/or acupuncture profession) What is your employment status at your Primary Business? Check only one. Full time (your usual hours of practise are 30 hours or more per week or this is your official status with your employer) Part time (your usual hours of practise are less than 30 hours per week or this is your official status with your employer) Casual (your official status with your employer is on an as needed basis) What is your primary role at your Primary Business? Check only one. Administrator Manager Salesperson Consultant Owner/Operator Service Provider Instructor/Educator Quality Management Specialist Researcher What are the major services that you provide at your Primary Business? Check as many as are applicable. Acute Care Critical Care General Service Provision Continuing Care Comprehensive Primary Care Chronic Disease Prevention and Management Public Health Mental Health and Addiction Primary Maternity Care Cancer Care Geriatric Care Palliative Care Sales Quality Management Post Secondary Education Consultation Research Other Areas Administration Other Area of Direct Service Consultation 4 P age

What is your primary practice setting at your primary business? Check only one. Hospital Group Health Centre (Sault Ste. Marie) Rehabilitation Facility Nurse Practitioner Led Clinic Mental Health and Addition Facility Other Group Practice Office Residential/Long Term Care Facility Assisted Living Residence/Supportive Housing Client s Environment Post Secondary Educational Institution Community Health Centre (CHC) Pre School/School System/Board of Education Family Health Team (FHT) Children Treatment Centre (CTC) Community Care Access Centre (CCAC) Cancer Centre Independent Health Facility Telehealth Ontario or other Telephone Health Advisory Service Spa Health Related Business/Industry Solo Practice Office Board of Health/Public Health Laboratory/Public Health Unit Association/Government/Regulatory Organization/Non Government Organization Other place of work What is the age range of your clients at your Primary Business? Check as many as are applicable. Under 18 years Adults Seniors (65 years and up) All ages t applicable Second Business (if applicable) Facility Name Street No. & Name (Required) Suite No. City (Required) Province (Required) Country (Required) Postal Code (Required) Website Telephone (Required) Ext. Fax What is your employment relationship at your second business? Check only one. Permanent (indeterminate duration of employment and guaranteed or fixed practice hours per week) Temporary (fixed duration of employment, based on a defined start date and end date) Casual (on an as needed basis) Self employed (a person who operates his or her own enterprise in the TCM and/or acupuncture profession) What is your employment status at your second business? Check only one. Full time (your usual hours of practise are 30 hours or more per week or this is your official status with your employer) Part time (your usual hours of practise are less than 30 hours per week or this is your official status with your employer) Casual (your official status with your employer is on an as needed basis) What is your primary role at your second business? Check only one. Administrator Manager Salesperson Consultant Owner/Operator Service Provider Instructor/Educator Quality Management Specialist Researcher 5 P age

What are the major services that you provide at your second business? Check as many as are applicable. Acute Care Critical Care General Service Provision Continuing Care Comprehensive Primary Care Chronic Disease Prevention and Management Public Health Mental Health and Addiction Primary Maternity Care Cancer Care Geriatric Care Palliative Care Sales Quality Management Post Secondary Education Consultation Research Other Areas Administration Other Area of Direct Service Consultation What is your primary practice setting at your second business? Check only one. Hospital Group Health Centre (Sault Ste. Marie) Rehabilitation Facility Nurse Practitioner Led Clinic Mental Health and Addition Facility Other Group Practice Office Residential/Long Term Care Facility Assisted Living Residence/Supportive Housing Client s Environment Post Secondary Educational Institution Community Health Centre (CHC) Pre School/School System/Board of Education Family Health Team (FHT) Children Treatment Centre (CTC) Community Care Access Centre (CCAC) Cancer Centre Independent Health Facility Telehealth Ontario or other Telephone Health Advisory Service Spa Health Related Business/Industry Solo Practice Office Board of Health/Public Health Laboratory/Public Health Unit Association/Government/Regulatory Organization/Non Government Organization Other place of work What is the age range of your clients at your second business? Check as many as are applicable. Under 18 years Adults Seniors (65 years and up) All ages t applicable Third Business (if applicable) Facility Name Street No. & Name (Required) Suite No. City (Required) Province (Required) Country (Required) Postal Code (Required) Website Telephone (Required) Ext. Fax What is your employment relationship at your third business? Check only one. Permanent (indeterminate duration of employment and guaranteed or fixed practice hours per week) Temporary (fixed duration of employment, based on a defined start date and end date) Casual (on an as needed basis) Self employed (a person who operates his or her own enterprise in the TCM and/or acupuncture profession) 6 P age

What is your employment status at your third business? Check only one. Full time (your usual hours of practise are 30 hours or more per week or this is your official status with your employer) Part time (your usual hours of practise are less than 30 hours per week or this is your official status with your employer) Casual (your official status with your employer is on an as needed basis) What is your primary role at your third business? Check only one. Administrator Manager Salesperson Consultant Owner/Operator Service Provider Instructor/Educator Quality Management Specialist Researcher What is your primary practice setting at your third business? Check only one. Hospital Group Health Centre (Sault Ste. Marie) Rehabilitation Facility Nurse Practitioner Led Clinic Mental Health and Addition Facility Other Group Practice Office Residential/Long Term Care Facility Assisted Living Residence/Supportive Housing Client s Environment Post Secondary Educational Institution Community Health Centre (CHC) Pre School/School System/Board of Education Family Health Team (FHT) Children Treatment Centre (CTC) Community Care Access Centre (CCAC) Cancer Centre Independent Health Facility Telehealth Ontario or other Telephone Health Advisory Service Spa Health Related Business/Industry Solo Practice Office Board of Health/Public Health Laboratory/Public Health Unit Association/Government/Regulatory Organization/Non Government Organization Other place of work What are the major services that you provide at your third business? Check as many as are applicable. Acute Care Critical Care General Service Provision Continuing Care Comprehensive Primary Care Chronic Disease Prevention and Management Public Health Mental Health and Addiction Primary Maternity Care Cancer Care Geriatric Care Palliative Care Sales Quality Management Post Secondary Education Consultation Research Other Areas Administration Other Area of Direct Service Consultation What is the age range of your clients at your third business? Check as many as are applicable. Under 18 years Adults Seniors (65 years and up) All ages t applicable B. Concurrent Registration in the Traditional Chinese Medicine Profession Concurrent Registration Outside of Canada t Applicable (skip to the next section) I am currently registered to practise as a Traditional Chinese Medicine Practitioner and /or an Acupuncturist in countries outside of Canada. Provide up to three countries where you are currently registered to practise the TCM profession: 1. 2. 3. 7 P age

Concurrent Registration in Canada or the USA t Applicable (skip to the next section) I am currently registered to practise as a Traditional Chinese Medicine Practitioner and/or an Acupuncturist in Canada or the USA. Provinces/territories or states other than Ontario where I am currently registered to practise (choose as many as are applicable): Alberta British Columbia State(s) in USA: Manitoba New Brunswick 1. Newfoundland rthwest Territories 2. va Scotia Nunavut 3. Prince Edward Island Quebec Saskatchewan Yukon Territory Other C. Education Related to the Traditional Chinese Medicine Profession If you have completed additional education related to your TCM profession since registration, complete this section. If you have not completed any additional education related to your TCM profession since registration, select Not Applicable. t Applicable (skip to next section) Level of Education Diploma Baccalaureate Master Doctorate Professional Doctorate Other Institution of Graduation Canadian College or University (specify): Canadian Private Career College Out of Country Country of Graduation Canada USA Other (specify): Province/Territory, if education completed in Canada: State(s) if education completed in the USA: Year of Graduation: D. Education NOT Related to Traditional Chinese Medicine Profession If you have completed additional education that is not related to TCM since registration, complete this section. If you have not completed any additional education not related to TCM since registration, select Not Applicable. t Applicable (skip to next section) Level of Education Diploma Baccalaureate Master Doctorate Professional Doctorate Other Field of study for highest level of education completed that was not related to the TCM profession: General Rehabilitation Science Mathematics, Computer Information Sciences Medical Laboratory Science Health Administration/Management Public Administration Kinesiology and Exercise Science Public Health Health Professions and Related Clinical Sciences Gerontology Biological and Biomedical Sciences Psychology Social Sciences, Arts and Humanities Physical Sciences Business, Management, Marketing and Related Education Law Engineering Other Field of Study 8 P age

Country of graduation for highest level of education completed that was not related to the TCM profession: Canada Province/Territory, if education completed in Canada: USA State if education completed in the USA: Other (specify): Year of graduation for the highest level of education completed that was not related to the TCM profession: E. BUSINESS / PRACTICE TIME THROUGH THE YEAR Number of weeks you spent practising the TCM profession in the past 12 months across all of your practice sites or jobs. (NOTE: One practice day in any week = one week of practice; exclude your vacation time, sick time, on call and leave time greater than one week.) Maximum 52 weeks per calendar year Average number of hours spent practising the TCM profession per week in the past 12 months across all of your practice sites or jobs. (NOTE: Hours should be inclusive of all practice hours; e.g. include travel time between practice settings, preparation and service provision. Hours should exclude commuting and any time spent volunteering outside of the profession.) Maximum of 168 hours: 7 days/week x 24 hours/day Average number of weekly on call hours in the past 12 months. Enter the average number of on call hours per week across all practise sites. Hours indicated are inclusive of all on call hours, whether worked or not worked Proportion of weekly business / practice hours spent on each activity Percentage Time spent on direct professional services Time spent per week on direct health professional services, e.g. conducting tests, patient care, health promotion, dispensing/building/repairing health apparatuses % Time spent teaching Time spent per week teaching to prepare students for a health profession; e.g. post secondary teaching excluding clinical education [providing professional services while teaching] % Time spent on clinical education Time spent per week on clinical education only, e.g. providing professional services while teaching, across all practice sites % Time spent on research Time spent per week across all practice sites conducting research in the profession % Time spent on administration Time spent per week across all practice sites on administration in the profession % Time spent on all other activities Time spent per week across all practice sites on activities excluding direct professional services, teaching, research and administration Total: 100% % F. Practice Status My current practice status in the TCM profession is: Practising in profession in some capacity Working outside the profession and seeking work in the profession Working outside the profession and NOT seeking work in the profession t working and seeking work in the profession t working and NOT seeking work in the profession On leave not practising the profession because on leave 9 P age

G. Full Time/Part Time/Casual Work Preference What status do you most prefer with respect to working in the profession? Full time (30 hours or more per week) Part time (less than 30 hours per week) Casual (no predetermined fixed number of hours per week) 9. Professional Liability Insurance All members must comply with CTCMPAO s required professional liability coverage. For more information, refer to the Registration Policy on Professional Liability Insurance available on the CTCMPAO website. Insurance Information I hereby certify that I have the professional liability insurance in accordance with CTCMPAO s By Laws and I have attached a photocopy of my Certificate of Insurance to this Renewal Form. I confirm that my professional liability insurance meets the minimum required coverage: less than $1,000,000 coverage per claim Aggregate coverage no less than $5,000,000 more than $1,000 deductible per claim Insuring Company (not Broker): Expiry Date: / / (mm/dd/yyyy) Policy Number: (Found on your Certificate of Insurance) Member s Signature Date of Signature (mm/dd/yyyy) 10. Delegation Are you accepting delegation of any controlled act(s) from a regulated healthcare professional? If yes, indicate below: Performing a procedure in or below the surface of the cornea, in or below the surfaces of the teeth, including scaling of teeth Setting or casting a fracture of a bone or a dislocation of a joint Moving the joints of the spine Applying a form of energy Prescribing, dispensing, selling or compounding a drug Administering a substance by injection or inhalation Prescribing or dispensing, for vision or eye problems, subnormal vision devices Managing labour Prescribing a hearing aid for a hearing impaired person Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or device used inside the mouth to prevent the teeth from abnormal functioning Allergy challenge testing Putting an instrument, hand or finger: Beyond the external ear canal Beyond the point in the nasal passages where they normally narrow Beyond the larynx Beyond the opening of the urethra Beyond the labia majora Beyond the anal verge Into an artificial opening in the body 10 P age

Are you delegating any TCM authorized acts? If yes, specify both the act(s) and to which healthcare professional(s) or member of the public it was delegated to: Authorized Acts: Performing a procedure on tissue below the dermis and below the surface of a mucous membrane for the purpose of performing acupuncture. Delegated to: Member of the public Healthcare professional List the healthcare profession: Communicating a TCM diagnosis identifying a body system disorder as the cause of a person s symptoms using TCM techniques. Delegated to: Member of the public Healthcare professional List the healthcare profession: EMERGENCY In the past 12 months, have you performed a controlled act under the emergency exception in the Regulated Health Professions Act, 1991? If yes, indicate below: Performing a procedure in or below the surface of the cornea, in or below the surfaces of the teeth, including scaling of teeth Setting or casting a fracture of a bone or a dislocation of a joint Moving the joints of the spine Applying a form of energy Prescribing, dispensing, selling or compounding a drug Administering a substance by injection or inhalation Prescribing or dispensing, for vision or eye problems, subnormal vision devices Managing labour Prescribing a hearing aid for a hearing impaired person Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or device used inside the mouth to prevent the teeth from abnormal functioning Allergy challenge testing Putting an instrument, hand or finger: Beyond the external ear canal Beyond the point in the nasal passages where they normally narrow Beyond the larynx Beyond the opening of the urethra Beyond the labia majora Beyond the anal verge Into an artificial opening in the body 11 P age

11. Declaration of Registration Requirements Mandatory Declarations Please answer the questions below by checking the appropriate box next to each question. If your answer to any of the questions in this section changes following your submission of your Renewal Form, you must advise CTCMPAO no later than 30 days after the event occurs (unless otherwise stated) and provide written details with respect to any change. You do not have to include in your answers matters that have previously been reported in writing on your original application for registration or in an annual renewal form. a. Have you been found guilty of an offence under a federal, provincial or municipal law? (If yes, attach a detailed explanation and relevant documents to your Renewal Form and provide the information as soon as possible.) b. Has there been a finding of professional negligence or malpractice against you in any jurisdiction? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) c. Has there ever been any finding of professional misconduct, incompetence or incapacity, or similar finding against you by another regulated profession in Ontario or to any regulated profession in another jurisdiction? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) d. Has there ever been a finding of professional misconduct, incompetency, or incapacity, any like finding, against you in Ontario in relation to the profession or another health profession, or in another jurisdiction in relation to the profession of TCM or another health profession? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) e. Is there a current proceeding against you involving an allegation of professional misconduct, incompetence or incapacity, or any similar proceeding, in Ontario or in any other jurisdiction, in relation to the profession of TCM or another profession? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) f. If you answered yes to one or more of the questions above, have you provided the details for all findings, convictions, cases and proceedings to CTCMPAO in writing? (If yes, indicate by checking the appropriate box; there is no need to resend the details unless asked. If no, indicate by checking the appropriate box and attach a detailed explanation and relevant documents to your Renewal Form.) N/A g. Have you ever made an application for registration as a Traditional Chinese Medicine Practitioner and/or an Acupuncturist in any other jurisdiction that was refused? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) h. Have you ever had an application for registration rejected by a regulatory college in Ontario or in another jurisdiction? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) i. Have you ever been unsuccessful in an attempt to pass a registration examination for a regulated health profession in Ontario or in another jurisdiction? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) j. Has there ever been a court proceeding brought against you alleging that you held yourself out as, or practising as a regulated health professional without being so registered? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) 12 P age

k. If you were previously registered with another body responsible for the regulation of a profession, and you ceased being registered, were you in good standing, (i.e., all fees paid, all information provided, no outstanding investigations, proceedings or sanctions) at the time you ceased being registered? (If no, attach a detailed explanation and relevant documents to your Renewal Form.) l. If you are a member of another regulated profession, did you ever fail to comply with any obligation to pay fees or provide information to the regulator? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) m. If you are a member of another regulated profession, has an investigation by the regulator ever been initiated in respect of you? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) n. If you are a member of another regulated profession, has the regulator ever imposed a sanction on you? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) N/A N/A N/A N/A o. Is there any other event that would provide reasonable grounds for the belief that you will not practise TCM and/or acupuncture in a safe and professional manner? (If yes, attach a detailed explanation and relevant documents to your Renewal Form.) 13 P age

0 12. Member s Declaration Read the following conditions of the declaration carefully, sign and date the declaration and return the completed Registration Renewal Application Form to CTCMPAO. I confirm that I will comply with each condition and have indicated my compliance by checking the box next to each condition: I solemnly declare that the contents of this Registration Renewal Application Form, including all attachments, are true and complete to the best of my knowledge and belief. I acknowledge that it is professional misconduct to practice TCM and/or traditional Chinese acupuncture when suspended. I understand that signing receipts for TCM and/or traditional Chinese acupuncture treatments while suspended may be considered to be insurance fraud and that CTCMPAO will investigate complaints and may take action. I understand and agree that any false or misleading statements may constitute professional misconduct and may result in the revocation of my certificate of registration and I may face disciplinary proceedings. I acknowledge that the information provided on this form is used by CTCMPAO to administer the Regulated Health Professions Act, 1991, the Traditional Chinese Medicine Act, 2006, the Regulations under these Acts, the By Laws, Policies, Standards of Practice, Guidelines and programs related to the governance of the profession; and that the information is collected, used and disclosed in accordance with those documents. I am responsible to pay the annual renewal fee and submit the Application for Registration Renewal to the Registrar on or before June 1 st of every year, even if the Registrar fails to mail a notice or I fail to receive such a notice. I understand that I must notify the Registrar in writing within thirty (30) days of any change of location of practice or employment, business name of practice, home and mailing addresses, phone number and/or email address. I understand that failing to abide by the terms of this written undertaking given by myself to CTCMPAO may constitute as an act of professional misconduct pursuant to Ontario Regulation 318/12. Declared By: Member Name Registration Number Member s Signature Date of Signature (mm/dd/yyyy) 14 P age

13. Payment 2014 2015 Registration Renewal Fees (select one) Other Fees (select if applicable) General $1142.43 ($1011.00 + HST) Late Penalty $342.73 (30% of Renewal Grandparented $1142.43 ($1011.00 + HST) Fee + HST) Important information about your 2014 2015 fees: Completed Renewal Forms must be postmarked before June 1, 2014, 11:59 p.m. EST. Renewal Forms that have been postmarked after June 1, 2014, 11:59 p.m. EST will be considered late and a late penalty fee in addition to the registration renewal fee will apply. Incomplete Renewal Forms will be returned with a deficiency notification. Deficiencies must be addressed and a complete Renewal Form must be submitted before June 1, 2014, 11:59 p.m. EST or the late fee will apply. Method of Payment Certified Cheque / Money Order (made payable to the College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario or CTCMPAO, for the amount of your class of Registration Renewal above) Mail your complete application with payment and all necessary documents to: Registrar CTCMPAO 163 Queen Street East, 4 th Floor Toronto, ON M5A 1S1 15 P age

Notice of Resignation NOTICE ONLY FOR MEMBERS RESIGNING FROM THE CTCMPAO Members cannot submit resignations online. To declare your resignation from CTCMPAO, send an email to registration@ctcmpao.on.ca or mail a letter to CTCMPAO and indicate your intention to resign and the date on which your resignation will take effect. CTCMPAO will contact resigning members to provide them with the appropriate forms to complete. Please be advised that resigning members will be required to comply with the following conditions of resignation: Once a member resigns his or her membership, the member cannot use the protected title(s) and designation (s) Traditional Chinese Medicine Practitioner (R.TCMP) and/or an Acupuncturist (R.Ac) or Provisional Traditional Chinese Medicine Practitioner (R.TCMP [Prov]) and/or Provisional Acupuncturist (R.Ac [Prov]), a variation or abbreviation or an equivalent in another language in Ontario. Once a member resigns his or her membership, the member cannot hold himself or herself out as a person who is qualified to practice in Ontario as a Traditional Chinese Medicine Practitioner and /or an Acupuncturist. Once a member resigns his or her membership, the member cannot perform the controlled acts authorized to members of CTCMPAO. After a member resigns, he or she remains subject to CTCMPAO for professional misconduct referable to the time when he or she was a member. If the resigning member wishes to apply for registration with CTCMPAO in the future, the member will be subject to the standards and registration requirements in effect at the time of his or her application. Prior to the member s resignation, the member will return his or her Certificate of Registration, walletsize certificate and/or related badges to the Registrar. Resigning members must take reasonable steps to notify each patient/client for whom the member has primary responsibility of the member s intended practice closure and ensure their records are transferred to successors or another member or are otherwise retained or disposed in a secure manner. 16 P age

Notice of Inactive Class NOTICE ONLY FOR MEMBERS WISHING TO APPLY FOR INACTIVE CLASS Members cannot submit applications for Inactive class membership online. Members who wish to change their class of registration to Inactive must download and complete a copy of the fillable Application for Certificate in the Inactive Class of Registration available on the CTCMPAO website at www.ctcmpao.on.ca, print and submit by mail to: Registrar CTCMPAO 163 Queen Street East, 4 th Floor Toronto, ON M5A 1S1 Pursuant to Ontario Regulation 27/13, Registration (the Registration Regulation ), made under the Traditional Chinese Medicine Act, 2006 (TCM ACT), members in the Grandparented and General class may apply to the Inactive class of membership. The purpose of the certificate in the Inactive class of registration is to allow Grandparented and General class members to remain as members of CTCMPAO when they anticipate that they will not be practising in Ontario for a period of time (for example when on parental, sick or educational leave or practising in other jurisdictions). If a member is granted a certificate in the Inactive class of registration, the following terms, conditions and limitations will attach to the certificate of registration: 1. Members cannot engage in the practice of TCM in the province of Ontario, 2. Members cannot supervise the practice of the TCM profession in the province of Ontario; and 3. Members cannot make any claim or representation to having any competence in the TCM profession in the province of Ontario. Members registered in the Inactive class will continue to be required to comply with all other requirements and terms, conditions and limitations imposed on members registered in the Grandparented /General class, including: Annual renewal of registration; Duty to self report any offence findings, professional negligence/malpractice or misconduct as per section 5(1) of the Registration Regulation. There is a class transfer fee of $151.65 + HST to apply for Inactive class membership. The Inactive class fee for the 2014 2015 registration year is $283.08 + HST. When a member in the Inactive class is reissued his or her certificate of registration, members pay the annual fee as outlined in CTCMPAO s By Laws. For more information, please refer to the Policy for Certificate in the Inactive Class of Registration (available on our website at www.ctcmpao.on.ca). 17 P age