APPLICANTS IDENTIFICATION
Gender  
BCSRT Member #
(if applicable):
 
Title:  
Surname:  
Usual first name:  
Middle Initials:  
Maiden or
Previous Surname
(if applicable):
 
Date of Birth:
 
 /   / 
MM / DD / YEAR
Application Type:   New     Renewal     Reinstatement
Membership Applied For:   Registered $85
Associate $20
Corporate $75
Student $15
Permanent Mailing Address
( #, street, R.R#,.P.O.Box#):
 
City/Town:  
Province:  
Postal Code:  
Home Phone:   ( ) - -
Bus. Phone:   ( ) - - Ext.:
E-mail:  
EDUCATION
Name / Location of Institution Attended for Respiratory Therapy Training:  
Date Graduated:  
 /   / 
MM / DD / YEAR
VERIFICATION OF SUCCESSFUL COMPLETION OF APPROVED EXAMINATION IN RESPIRATORY THERAPY
Are you a new graduate?   Yes     No
Eligible to write?   Yes     No
Exam Complete?   Yes     No
CSRT Registry # (if completed):  
RECORD OF EMPLOYMENT OVER THE PAST 12 MONTHS
Employer:  
Address:  
Postal Code:  
Telephone:   ( ) - - Ext.:
Start Date:  
Classification:   Full Time     Part Time     Casual
Approx # Hours Worked per week:  
Employer:  
Address:  
Postal Code:  
Telephone:   ( ) - - Ext.:
Start Date:  
Classification   Full Time     Part Time     Casual
Approx # Hours Worked per week:  
ADDITIONAL COMMENTS
Please Let Us Know About Any Other Significant Information:  
DECLARATION
   
    I have read, understood, and agreed to the above Articles.
    I authorize the (C.B.R.C.) Canadian Board of Respiratory Care to release my examination results
(pass/fail) to the B.C.S.R.T. for the sole purpose of determining eligibility for B.C.S.R.T. registration.
    Have you ever been disciplined by, or are you currently being investigated by any Body responsible
for the regulation of this or any other profession?
Yes     No
    In applying for membership of the British Columbia Society of Respiratory Therapists, I hereby acknowledge that I have an obligation to observe, respect and uphold the principles, rules and standards of conduct as set forth in the Constitution and By-laws and Code of Ethics of this Society.
Plese select payment method:   I want to pay online using my VISA or Mastercard credit card
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I paid BCSRT dues via the CSRT

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B.C.S.R.T.
P.O. Box 4760
Vancouver, British Columbia,
V6B 4A4, Canada