McMaster

University

Program in Occupational Health and Environmental Medicine (POHEM)
Hamilton, OntarioL8N 3Z5
CANADA
Indicate preferred program
Full-time
Part-time

Application for Admission to

Diploma in Occupational Health and Safety (DOHS)Program

(PLEASE PRINT OR TYPE. YOU MAY USE TAB KEY TO ADVANCE WITHIN FORM)

PERSONAL DATA
LEGAL SURNAME / ALL LEGAL GIVEN NAMES IN FULL / GENDER
F M / FORMER SURNAME (if applicable)
SOCIAL INSURANCE NUMBER / MARITAL STATUS
Single / Married
Divorced / Widowed
/ DATE OF BIRTH
YEAR / MONTH/ DAY
/ / / NATIVE LANGUAGE
English / French
Other
PERMANENT ADDRESS: / MAILING ADDRESS: if different from permanent please complete
House Number and Street / Apt. / House Number and Street / Apt.
City / Province/State / City / Province/State
Country / Postal Code / Country / Postal Code
Telephone: / FAX:
Email:
STATUS IN CANADA:
Country of Birth:
0 CANADIAN CITIZEN
1 LANDED IMMIGRANT
2 STUDENT VISA
3 OTHER (Specify) / NON-CANADIANS
Country of Citizenship:
Proposed Date of Entry into Canada:
OR Date Permanent Resident Status was Granted:
ACADEMIC HISTORY
(NOTE: Transcripts will be required upon acceptance)
YEAR ENTERED / ACADEMIC INSTITUTION AND LOCATION / LANGUAGE OF INSTRUCTION / DEGREE OR DIPLOMA COMPLETED / YEAR COMPLETED
APPLICATION DATA
Have you ever been given a McMasterstudent number? / YES / NO / If yes, what is your number:
Have you applied to McMaster previously for any courses? / YES / NO / If yes, when:
Have you corresponded with McMaster previously? / YES / NO / If yes, with whom:
Place of Employment:
Employment Address:
Telephone:
Position Held:
Professional and Related Certification Held ( eg RN FRCP, CRSP, PEng, etc.):

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PROFESSIONAL WORK EXPERIENCES, WITH DATES:
DESCRIPTION OF YOUR CURRENT JOB:
ANY FURTHER COMMENTS (e.g., What are your reasons for wanting to take this course?):
I hereby certify that all statements on this form are correct and complete and that my educational and professional activities to this date have been fully disclosed herein.
THIS APPLICATION MUST BE SIGNED:
SIGNATURE OF APPLICANT / DATE
Please indicate how you learned about this program:(please specify relevant information such as name of website, name of journal)
Word of Mouth
Website / l
Other (e.g. Journal)
YR / TYPE / DEG / FAC / YEAR / PROG / Status / F/P
SEND COMPLETED APPLICATION TO:
Ms. Jolene Tadros, Administrative Assistant
Program in Occupational Health and Environmental Medicine
McMasterUniversity, Heath Sciences Centre
1200 Main Street West, Room 3H50
Hamilton, ON L8N 3Z5 CANADA
Phone: (905) 525.9140 Ext. 22333
Fax: (905) 521-8426
Email:
Website:

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