Application for Enrollment

Contact information:

Given name & middle initial:

Last name:

Address:

City:

Province & postal code:

Phone number w/area code:

Next of kin & phone number:

Education Requirements:

Before your application can be processed we require by fax ( 506 773-6896 )

Or drop of a copy of the requirememts listed below to.

Miramichi Health Training Centre 2 Johnson Street, Miramichi.

Proof of grade 12 diploma

or

GED equivalent

Criminal background check within the last 3 years

Criminal backround check available from local police station.

If a pardon in needed it may be obtained from

canadianpardon.ca or call 1 800 298-5520

Uniform Information:

Please indicate pant size to be ordered:

Please indicate top size to be ordered:

Indicate color preference:

Please indicate method of payment:

Permission to use photos taken for advertising purposes in ads or website:

Yes

No

Date (dd / mm / yyyy):