Molecular, Biochemical, Cytogenetics Exam Registration Form Name:* First Last Address:* Street AddressCityProvincePostal CodeTelephone:* Area Code - Phone Number E-mail:*Select Specialty Examination 1:*SelecBiochemical (Clinical)Biochemical (laboratory)CytogeneticsMolecularSelect Specialty Examination 2:Select Biochemical ClinicalBiochemical LabCytogeneticsMolecularTraining Site:*SelectMcGill UniversityMcMaster UniversityUniversité de Montréal, Hôpital Ste-JustineUniversity of AlbertaUniversity of British ColumbiaUniversity of CalgaryUniversity of ManitobaUniversity of OttawaUniversity of TorontoOtherTraining Site Other:Application for Special Accommodations: (Applicants must complete and submit the Application for Special Accommodations to the Administrative Office)*YESNOIN CASE OF AN EMERGENCY - If you would like us to contact someone on your behalf, please provide the following:Emergency Contact Name: First Last Emergency Contact Telephone #: Area Code - Phone Number Emergency Contact E-mail:EXAMINATION FEES (due January 15, 2020)General Written Examination ONLY: $700 CADFull Examination (General & Specialty Written/OSLEs): $2,000 CADSpecialty Examination ONLY (Specialty Written/OSLEs): $1,300 CADPayments are accepted by cheque or money order payable to the CCMG and sent to: CCMG 4 Cataraqui Street Suite 310, Kingston, ON K7K 1Z7Candidates sitting two (2) specialty examinations in the same examination cycle must submit an additional $1,300 (includes the Specialty Written and OSLEs).A late registration fee of $300 will be applied to registrations submitted after January 15, 2020. Late applications will not be received after February 15.Select the Examination Option: (1)General Written Examination ONLYFull Examination (General & Specialty Written/OSLEs)Specialty Examination ONLY (Specialty Written/OSLEs)General Written Examination – TBD May 2020Language of General Written Examination :GW EnglishGW FrenchSpecialty Written Examination - TBD June 2020Language of Specialty Written Examination: SW EnglishSW FrenchOSLEs – Saturday, 2020Language of OSLEs:OE EnglishOE FrenchSitting 2nd Specialty ExaminationFee for sitting (2) two specialty examinations in the same examination cycle: 2nd ExamLate Fee (if applying after January 15 and before February 15)Late fee: (Applications after February 15 will not be accepted.)Late FeeThis confirms my intent to sit for the next cycle of CCMG examinations.Signature:*Date:*SubmitResetTHIS COMPLETED FORM WITH YOUR EXAMINATION FEE PAYMENT MUST BE RECEIVED BY THE CCMG OFFICE BY THE JANUARY 15, 2020 DEADLINE.A $300 FEE MUST BE APPLIED TO REGISTRATIONS SUBMITTED AFTER JANUARY 15, 2020. APPLICATIONS RECEIVED AFTER FEBRUARY 15 WILL NOT BE ACCEPTED.Total:
