NDAEB Withdrawal Request Form

*1 Withdrawal fees will apply based on the actual date the NDAEB office receives this withdrawal request! *2 Applicants withdrawing due to circumstances related to illness or emergency MUST accompany this request with a verifiable physician’s certificate or written verification provided by a religiose leaser or other professional. NDAEB Withdrawal Request Form Candidates wishing to withdraw their NDAEB Written Examination or Clinic Practice Evaluation (CPE) application may do so at any time by completing the following ‘Withdraw Request Form’. • All withdrawals must be signed by the applicant (or designated representative) submitted to the NDAEB office in writing, before the Scheduled Written Exam or CPE date, by either: Email: [email protected] (Preferred) OR Fax: 613-526-5560. • All Written Exam/CPE application withdrawals are subject to a withdrawal fee. Please visit our website: www.ndaeb.ca to download the Candidate Handbook and review the Withdrawal Fees Guide. ___________________________________________________________________________________________________________ Last Name: ________________________________________First Name: _____________________________________________ Email: ____________________________________________________________________________________________________ □NDAEB Certificate number: ________________or □ NDAEB Registration Number______________________________ ___________________________________________________________________________________________________________ To whom it may concern, I, ____________________________________________________________________________________ (Full Name) would like to withdraw my application today*1 _______________________________________________ (Date of withdrawal request yyyy/mm/dd) from the (please select one): □NDAEB Written Exam taking place on ____________________________________________________ (W.E date yyyy/mm/dd) □NDAEB CPE taking place on ___________________________________________________________ (CPE date yyyy/mm/dd) Reason for Withdrawal*2: I am withdrawing my application for the following reason/s … ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 1

*1Withdrawal fees will apply based on the actual date the NDAEB office receives this withdrawal request! *2 Applicants withdrawing due to circumstances related to illness or emergency MUST accompany this request with a verifiable physician’s certificate or written verification provided by a religiose leaser or other professional. Reason for Withdrawal Continued*2: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ I have read the candidate handbook and am aware that withdrawal fees will be assessed and apply based on the actual date the NDAEB office receives this withdrawal request, and that the NDAEB reserves the right to determine circumstances that qualify as grounds for withdrawal without financial penalty after reviewing and verifying the accompanied documentation in support of an illness or emergency. As stated in the Reason for Withdrawal portion of this form, my withdrawal request is due to illness/emergency/religious circumstances. Please find attached to this withdrawal request the following supporting documentation (If applicable): □Physician’s certificate note □Letter from a religious leader □Other (Please specify):______________________________________________________________________________________ Please Note: The NDAEB is committed to fairness, transparency and excellence in the availability and service it provides to candidates, stakeholders, and the public, and in keeping with NDAEB’s value of fairness to all involved. Therefore, due to the high demand for the CPE, candidates are not permitted to register for a CPE session to hold a place while also awaiting confirmation to attend formal education upgrading in lieu of CPE. If it is determined the candidate has registered for a CPE session while also registering for the same skills via education upgrading in lieu, the candidate will be penalized / assessed at least 50% of their CPE fees upon withdrawing from their scheduled CPE session. Signature: ________________________________________________ Date: _______________________________ NDAEB Withdrawal Form • 2024 2

RkJQdWJsaXNoZXIy MzA1NjE=