Page 4 of 4 SECTION D - DECLARATION (Completed by a qualified health care professional) I certify that the information I have provided is truthful and accurate to the best of my knowledge and is within my scope of practice. Printed name Signature Date Instructions to health care professionals: please complete the form and give it/email it back to the candidate. If you prefer to forward it directly to NDAEB, please email it to office@ndaeb.ca or Fax: (613) 526-5560. Medical stamp
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