Assessor Update Form

All fields that are red are required to be completed.

 

 

Section I

(all fields are to be completed)

First Name

Last Name

Telephone (B)

Telephone (H)

Email

 

 

 

Section II

(all fields are to be completed)

Employer

Job title

 

 

Home Address

Employer Address

   Address

  Address

   Address

  Address

   City

  City

   Province

  Province

   Postal Code

  Postal Code

   Phone #

  Phone #

 

Prefered Mailing Address  

French Language Proficiency:

 

Do you have an iPad (Gen 2 or greater)?

 

Qualifications: (Please submit an updated CV)

Years (E.G., 2004-2007)

Degree/Diploma

Institution

Major/Specialization

 

 

  Work Experience: (Please list up to 3 previous employers)

Years (E.G., 2004-2007)

Employer

Position

 

 

 

 

 

 

 

  

 Laboratory Professionals

 

Please select your area of expertise:

Other:

 

  

Diagnostic Imaging Professionals

 

Please select your area of expertise:

Modality

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supporting Infrastructure

:

 

If you have added an area of expertise, please indicate your qualifications below and submit an updated resume to accreditation@iqmh.org:

 

 

 

 

Please review the form prior to submission.

When submitting online:

  1. You must complete this form in one session
  2. Clicking on the “SUBMIT” button will transmit this form to IQMH Centre for Accreditation.

If you are submitting this form by email, please email it to rghosh@iqmh.org or fax it to 416-323-9324 and mark attn: Rhea Ghosh

 

The “Submit” button allows you to submit the complete and final form.
IMPORTANT: Modifications cannot be made after Submit.

 

Version 7.1(2019-02-14)