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 3, 2020)General Written Examination ONLY: $800 CADFull Examination (General & Specialty Written/OSLEs): $2,500 CADSpecialty Examination ONLY (Specialty Written/OSLEs): $1,700 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 3, 2020. Late applications will not be received after February 3.Select the Examination Option: (1)General Written Examination ONLYFull Examination (General & Specialty Written/OSLEs)Specialty Examination ONLY (Specialty Written/OSLEs)General Written Examination – Tuesday, May 12, 2020 – Accredited Training CentreLanguage of General Written Examination :GW EnglishGW FrenchSpecialty Written Examination - Wednesday, May 13, 2020 – Accredited Training CentreLanguage of Specialty Written Examination: SW EnglishSW FrenchOSLEs – Monday, June 15, 2020 – WinnipegLanguage 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 3 and before February 3)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 3, 2020 DEADLINE.A $300 FEE MUST BE APPLIED TO REGISTRATIONS SUBMITTED AFTER JANUARY 3, 2020. APPLICATIONS RECEIVED AFTER FEBRUARY 3 WILL NOT BE ACCEPTED.Total: