1500 Scotia One 10060 Jasper Avenue NW Edmonton AB T5J 4A2 PH 780-426-3990 TOLL FREE 1-800-661-7020 FAX 780-426-1877 APPLICATION FOR PROFESSIONAL LICENSEE (ENGINEERING) OR (GEOSCIENCE) INSTRUCTIONS & SUPPLEMENTAL INFORMATION: 1. Please print clearly. Review the information below carefully and submit all of the necessary supporting materials with your application form. Incomplete applications will not be processed. 2. Please e-mail your completed form and supporting documents to professionallicensee@apega.ca with the following subject line: Professional Licensee Application First Name Last Name 3. Your payment is processed following the receipt of your documentation. Application fees are non-refundable. APEGA will contact you VIA email if you are not eligible to apply 4. Once you receive your APEGA ID., you can check the status of your application by logging in to your Member Self-Service Centre. 5. All required documentation will need to be completed and submitted within 60 days from the receipt of your application confirmation email. Failure to do so will result in automatic withdrawal. I wish to apply for registration as a (choose one only): Professional Licensee (Engineering) Professional Licensee (Geoscience) 1. PERSONAL INFORMATION Mr. Ms. Last Name Given Full Name(s) DOB (MM/DD/YY) Country of Birth Canadian Citizen Mailing Address: Please check one Business Residence/Home Perm. Resident Company Name (if business address is selected): E-Mail Address: Business #: ( ) Home #: ( ) 2. POST SECONDARY EDUCATION Institution Location Dates Attended (Mo./Yr.) Graduation Date (Mo./Yr.) Deg. or Dipl. (abbrev. Title) Specialization or Discipline If your post-secondary education is from an institution(s) in Canada, please have transcripts and confirmation of graduation sent directly to APEGA from each academic institution in a sealed, unopened envelope that has been clearly marked by the institution with an official seal and/or stamp. If your post-secondary education is from an institution outside of Canada, you must obtain an academic assessment (WES ICAP report) of your academic records from World Education Services (WES).
3. DEFINED SCOPE OF PRACTICE AND WORK EXPERIENCE RECORD FORM (WER) Download the Work Experience Record, and read carefully the experience requirements, the scope development guidelines and the references requirements. 4. CHARACTER DECLARATION This part of the form must be completed in its entirety and any additional documents, as required where indicated below, are to be included as well. Failure to complete in full will cause delay and potential cancellation of the application without notification and no refund. Part 1: Identity Do you use any other name than what you have indicated on your application? YES NO If, please specify: Part 2: Status of Registration 1. Are you currently registered in a Defined/Limited Scope of Practice with another Canadian engineering or geoscience professional licensing body (Association) in Canada? If yes, please specify which Association Member Number: 2. Do you have an application to register for a Defined/Limited Scope of Practice with any other Canadian engineering or geoscience professional licensing body (Association) that is still pending? If, please specify: Date of Application (YR/MM/DD): 3. Have you ever been, or currently being, the subject of a suspension or undertaking, or have otherwise had restrictions placed upon you for a license to practice engineering or geoscience within a defined or limited scope, by a governing body of the profession outside of Alberta, including outside of Canada? If, please specify: 4. Have you ever been refused registration as a member (in a limited/defined scope of practice or otherwise) of any other Canadian engineering or geoscience professional licensing body? If, please specify: Part 3: Character 5. I am aware of or I have been involved in any criminal proceedings or complaint or disciplinary proceedings in any jurisdiction? If, specify If yes, please specify which Association Member Number: 6. I have pleaded guilty or I have been found to have committed any of the following (answer YES only for conduct for which a pardon has NOT been granted): a. An indictable offense or summary conviction offense under any Act of the Parliament of Canada or any Act in any province of Canada b. Unprofessional conduct or unskilled practice by any Canadian engineering or geoscience professional licensing body c. Unprofessional conduct or unskilled practice by any other Canadian professional licensing body d. Negligence due to unskilled practice of engineering or geoscience in any civil action e. Academic misconduct If, please specify:
Part 3: Character (Cont.) 7. I have pleaded guilty or I have been found to have committed conduct outside of Canada, similar to any conduct described in Question 6 (answer YES only for conduct for which a pardon has NOT been granted) If yes, please specify 8. I have had a civil judgement against me relating to fraud. 9. I have disobeyed an order of a court. 10. There are events, circumstances or conditions, other than those mentioned above that are potentially relevant to my competence to practice engineering or geoscience, including, without limitation, circumstances relating to chemical or substance abuse. 11. Is there any other matter regarding your registration that we should be aware of? DECLARATION I declare, that, with my signature below, I have read, understood, and have answered truthfully and completely the questions above. I also provide consent for APEGA to contact and collect any information from other provincial professional regulatory organizations that may be required to verify the information provided and for such other organizations to disclose my personal information for APEGA, or request additional information from me to satisfy the requirements for registration with APEGA. I also acknowledge that APEGA may disclose personal information about me contained within my application to APEGA to other provincial professional regulatory organization(s) related to matters of registration within the Profession. I hereby grant consent to APEGA to release electronically any information or records relevant to the application process to such individuals as may be required for the progression or consideration of my applications which consent is given with knowledge of the Personal Information Protection Act. I also declare that I am fully aware that any failure to disclose, omissions, or inaccuracies on this form may make me immediately subject to investigation by APEGA, as well as result in a complaint with my current home association. Signature (use mouse or stylus) Date: YR/MO/DY: NOTE: APEGA adheres to the privacy standards under PIPA regarding collection, use, disclosure, and retention of personal information. For a description of APEGA s Privacy Policy, please refer to our website at http://www.apega.ca/privacy.html. Furthermore, applying your signature, as indicated in Section 4: Character Declaration; only validates the Character Declaration. Applicant still MUST apply signature and date in the application fee section indicating payment, at the bottom of this form. 5. KNOWLEDGE OF PROFESSIONAL LAW & ETHICS I have passed the National Professional Practice Examination (NPPE) from the following certification association on the day of the month, of the year. te that if you have passed the NPPE with ASET on or after January 20, 2014 you are not required to write the exam again for your APEGA application NOTE: If you passed the NPPE with ASET prior to January 20, 2014, you will be required to pass the NPPE for your APEGA application. I will pass the National Professional Practice Examination to fulfill the registration requirements. (Check this if you have not written and passed the NPPE exam or if you have passed it for ASET for any session prior to Jan 2014) 6. ENGLISH LANGUAGE COMPETENCY English is my native language. I have attached a handwritten letter explaining why I am competent in the use of the English language. I have previously written the Test on English as a Foreign Language (TOEFL). Attach copy of TOEFL scoresheet. I will be writing the TOEFL to fulfil the registration requirements.
7. PAYMENT ENCLOSED REQUIREMENT CHECKLIST Completed, signed, and dated application form with payment information. Request for academic documents sent directly to APEGA from the institution(s) or WES ICAP Report (add link to academic documents) Proof of English competency Completed WER form (checking this box off confirms you have read and understood the required details of the WER form and read the scope guidelines sheet in the WER file) Confirmation of passing the NPPE (if applicable) Character Declaration filled out (in this form package) Copy of Gov t issued Personal Identification Document (eg. driver s licence, birth certificate, Passport) NOTE: front and back images for PR and Citizenship card are required 8. COMMENTS
APPLICATION FEE GST Included (GST#106728603) $525.00 GST included (non-refundable) Visa Master Card AMEX CC# Expiry Date: APEGA OFFICE USE Payment Member Number Order ID Date: Signature: Date