Name

Profession

Organization

Address

Address 2

Suite

City

Province

Postal Code

Phone

()    ext.

Fax

()  

E-mail

NAME OF FACILITY

(If same as professional's name above, re-enter the name here in the exact way that you would like it to appear for communication with RREES and the ROMS system. If someone within the facility has already registered for the facility (or under it), you should not enter this field. If you are registering for a second or more facilities, please communicate this intention to RREES via e-mail (Go to "E-Mail above))

FACILITY BILLING ADDRESS

(if different from above address)

Address

Address 2

Suite

City

Province

Postal Code

Phone

()    ext.

Fax

()  

E-mail

1. Licence / Certificate Number

LicensingBody

2. Area(s) of professional expertise: 

Message Therapy
Medicine
Nursing
Occupational Therapy
Physiotherapy
Psychiatry

Psychology
Rehabilitation Counseling/Case Management
Speech/Language

(specify):

  3. Which of the following describes your highest level of training?

Doctorate
Master's
Bachelor's
Other (specify):