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Application for Rehabilitation Assessor/Fitter/Dispenser Status Ministry of Health and Long-Term Care Assistive Devices Program (ADP) 5700 Yonge Street, 7th Floor Toronto ON M2M 4K5 Section 1 – Mailing Address PLEASE PRINT Last Name First Name Middle Initial Address Building Number Street Name Lot/Concession/Rural Route City/Town Suite/Apt Number Postal Code ON Business Telephone (include area code) Fax number (include area code) - Email Address - Section 2 - Details Device category for which you are applying. Note: A separate application is required for each category. (Refer to Attachment A for sub-categories) Conventional Limb Prostheses (Rehabilitation Assessor) Externally Powered Upper Limb Prostheses (Rehabilitation Assessor) Hearing Aids (Dispenser) Orthotics (Rehabilitation Assessor) Pressure Modification Devices - Hypertrophic Scar Management (Certified Fitter / Manufacturer Representative) Pressure Modification Devices - Lymphedema Management (Certified Fitter / Manufacturer Representative) If you are currently a registered authorizer, fitter, rehabilitation assessor or dispenser with the ADP, specify your authorizer number Indicate your profession Audiologist Certified Fitter Hearing Instrument Specialist Hearing Instrument Dispenser Occupational Therapist Physiotherapist Workshop Information Date (yyyy/mm/dd) Workshop / Date Received (yyyy/mm/dd) / / 4637-67E (2011/03) Approval Date (yyyy/mm/dd) / © Queen’s Printer for Ontario, 2011 Location / Permanent Number / Disponible en français Page 1 of 2 Section 3 - Experience Specify and briefly describe other relevant formal or informal educational programs, workshops, manufacturer’s training programs, conferences completed/attended in the past 5 years. Describe your experience in prescribing/assessing/fitting the device for which you are seeking ADP fitter/dispenser status. Section 4 - Employment Locations (hearing aid dispensers must provide ADP registered vendor address) Location 1 Employer’s Name Is this your preferred mailing address Yes No (Default to Mailing Address in Section 1) Address Building Number Street Name Lot/Concession/Rural Route City/Town Suite/Apt Number Postal Code ON Business Telephone (include area code) - Fax number (include area code) Email Address - Location 2 Employer’s Name Address Building Number Street Name Lot/Concession/Rural Route City/Town Suite/Apt Number Postal Code ON Business Telephone (include area code) - Fax number (include area code) Email Address - Location 3 Employer’s Name Address Building Number Street Name Lot/Concession/Rural Route City/Town Suite/Apt Number Postal Code ON Business Telephone (include area code) - Fax number (include area code) Email Address - Use Attachment B for additional locations Section 5 - Confirmation The information provided on this form is true, correct and complete to the best of my knowledge. I understand that I will have to sign and comply with the terms specified in the Authorizer Agreement and the Conflict of Interest Protocol. Date (yyyy/mm/dd) Signature X 4637-67E (2011/02) / / Page 2 of 2