This form must be completed by the applicant. Forms completed by a third party will
not be accepted.
PART B: Licence Requested
I am applying for:
I hereby apply for a licence to practice at the
PART C: Employment Information if applicable, are you currently employed?
Employment information is only required to be completed for all the employers for
whom you plan to use your EMA licence.
Please choose at least one employer from the drop down lists
If you are not employed please choose "Not Employed" and if your employer
does not appear on the list please choose "Other" and add the employer
Add an employer
HLTH 9700 - Last Revised:
October 25, 2019
PART D: Applicant questionaire
When completing the questions that follow, the applicant should read the questions
carefully and answer the questions truthfully. If the applicant has any questions
regarding how to respond, they are strongly encouraged to contact the Branch for
clarification. Should the applicant provide any inaccurate, false or misleading
information or omit any required information, their application may be immediately
cancelled, and the Board may use this information when making a determination of good
character on future applications.