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IDENTIFICATION Member number Address First name City Province/State Last name Country Postal code E-mail Telephone – Home Telephone – Work INSTRUCTIONS Remember to provide supporting documents for each activity. Refer to the Summary Table of Continuing Education Activities to find out which supporting documents are eligible. Once you have filled out the form, save it and e-mail it along with the supporting documentation. 2011-2013 PERIOD Limits apply to the hours that you may report for the following activities: Conferences, workshops, seminars, symposiums or conventions (limit of 15 hours) Delivery or preparation of a presentation or leading workshops as part of a conference, seminar, symposium or convention (limit of 10 hours) Writing published specialized articles or papers (limit of 15 hours) Participation in technical committees (limit of 10 hours) Participation in research projects and self-study activities (limit of 5 hours) DECLARATION AND SIGNATURE I solemnly certify and affirm that the information provided in this form and all attached documents are true, exact and unaltered. Signature Date CONTINUING EDUCATION ACTIVITY REPORT FORM 2011-2013 Ordre des ingénieurs du Québec Gare Windsor, 1100, avenue des Canadiens-de-Montréal, Suite 350, Montréal (QC) H3B 2S2 514 845-6141 or 1 800 461-6141 ext. 2398 fco@oiq.qc.ca Last update : 2017-10-06
Transcript of CONTINUING EDUCATION ACTIVITY REPORT FORM 2011-2013 › Documents › DAP › dev_prof › ... ·...
IDENTIFICATION
Member number Address
First name City Province/State
Last name Country Postal code
E-mail Telephone – Home Telephone – Work
INSTRUCTIONS
Remember to provide supporting documents for each activity. Refer to the Summary Table of Continuing Education Activities to find out which supporting documents are eligible.
Once you have filled out the form, save it and e-mail it along with the supporting documentation.
2011-2013 PERIOD
Limits apply to the hours that you may report for the following activities:
Conferences, workshops, seminars, symposiums or conventions (limit of 15 hours) Delivery or preparation of a presentation or leading workshops as part of a conference,
seminar, symposium or convention (limit of 10 hours) Writing published specialized articles or papers (limit of 15 hours) Participation in technical committees (limit of 10 hours) Participation in research projects and self-study activities (limit of 5 hours)
DECLARATION AND SIGNATURE
I solemnly certify and affirm that the information provided in this form and all attached documents are true, exact and unaltered.
Signature Date
CONTINUING EDUCATION ACTIVITY REPORT FORM 2011-2013
Ordre des ingénieurs du Québec Gare Windsor, 1100, avenue des Canadiens-de-Montréal, Suite 350, Montréal (QC) H3B 2S2 514 845-6141 or 1 800 461-6141 ext. 2398 [email protected] Last update : 2017-10-06
ACTIVITY REPORT – 2011-2013 PERIOD
ACTIVITY #1
Start date End date
Type of activity
Type of content (subject)
If other, specify
Name of the activity
Type of provider Provider
Location (City/Province/Country) Duration in hours
REQUIRED SUPPORTING DOCUMENTATION – ACTIVITY #1
Document no. 1: File name
Document no. 2: File name
Document no. 3: File name
ACTIVITY #2
Start date End date
Type of activity
Type of content (subject)
If other, specify
Name of the activity
Type of provider Provider
Location (City/Province/Country) Duration in hours
REQUIRED SUPPORTING DOCUMENTATION – ACTIVITY #2
Document no. 1: File name
Document no. 2: File name
Document no. 3: File name
Ordre des ingénieurs du Québec Gare Windsor, 1100, avenue des Canadiens-de-Montréal, Suite 350, Montréal (QC) H3B 2S2 514 845-6141 or 1 800 461-6141 ext. 2398 [email protected]
ACTIVITY REPORT – 2011-2013 PERIOD (continued)
ACTIVITY #3
Start date End date
Type of activity
Type of content (subject)
If other, specify
Name of the activity
Type of provider Provider
Location (City/Province/Country) Duration in hours
REQUIRED SUPPORTING DOCUMENTATION – ACTIVITY #3
Document no. 1: File name
Document no. 2: File name
Document no. 3: File name
ACTIVITY #4
Start date End date
Type of activity
Type of content (subject)
If other, specify
Name of the activity
Type of provider Provider
Location (City/Province/Country) Duration in hours
REQUIRED SUPPORTING DOCUMENTATION – ACTIVITY #4
Document no. 1: File name
Document no. 2: File name
Document no. 3: File name
Ordre des ingénieurs du Québec Gare Windsor, 1100, avenue des Canadiens-de-Montréal, Suite 350, Montréal (QC) H3B 2S2 514 845-6141 or 1 800 461-6141 ext. 2398 [email protected]
