Internationally Educated Medical Laboratory Technologists (IEMLT) Bursary Application Form

IEMLT Bursary Application Form

Step 1 of 5

Personal Information

* Denotes required field

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

If ZIP/postal code is not applicable, please enter '000000'.

Phone

Education/Licensing Information

* Denotes required field

In which country do you currently live?

In which country(s) do you currently hold registration/licensure/certification as a medical laboratory technologist (MLT)?

In which country did you receive your college or university diploma or degree from a medical laboratory technologist program?

Is your education and work experience at the technologist level for clinical/diagnostic human testing and NOT for research, plants, or animals?

Do you currently, or have you ever held certification as a medical laboratory technologist in any province or territory in Canada?

Required Documents

* Denotes required field

Please upload all documents in either .pdf, .jpg, or .png format. Reimbursement will be eligible for costs incurred on, or after July 19, 2022

A copy of your English-translated Passport as a supporting identification document.

Click or drag files to this area to upload. You can upload up to 2 files.

Note: We do not need all of the pages in your passport, only the pages with your full legal name and signature. For example, if your photo, full legal name, and date of birth are on one page and your signature is on another page, we will need both pages.

Click or drag a file to this area to upload.

A copy of your Medical Laboratory Technologist diploma or degree from a country other than Canada.

Click or drag files to this area to upload. You can upload up to 2 files.

Note: Our team may be unable to verify the document if it is not in English, this may lead to delays in your application. Please submit an English translation or verification document.

Click or drag a file to this area to upload.

Have you initiated the Prior Learning Assessment (PLA) process with the Canadian Society of Medicine Laboratory Science (CSMLS)?

Disbursement Requirements

To facilitate the electronic transfer of funds to your bank account and to issue a T4A, as the bursary is taxable income, HEABC requires a valid Social Insurance Number (SIN) as well as the below information:

Date of Birth

Do you hold a Canadian Social Insurance Number (SIN)?

Citizenship

Do you have a bank account with a Canadian Financial Institution?

Consent and Acknowledgement

Please read the following and check the boxes below to finalize and submit your application:

Collection of Personal Information

All personal information related to your participation in the Internationally Educated Medical Laboratory Technologists (IEMLT) Credential Assessment and Education Bursary Program is collected in accordance with the applicable privacy legislation, for the purposes of administering the candidate’s participation in the program, facilitating the evaluation process, funding verification, entitlement, disbursement of financial stipends, grants, reimbursement or waiver programs, statistical analytics, surveys, research, potential recruitment, employment, and other such related purposes.

Consent and Agreement

By submitting your supporting documents, you are consenting to Health Match BC using the personal information provided to them and sharing said personal information in the future with the following entities: Ministry of Health, Canadian Society of Medicine Laboratory Science, Fraser Health Authority, Interior Health Authority, Island Health Authority, Northern Health Authority, Vancouver Coastal Health Authority, Provincial Health Services Authority, Providence Health Care, LifeLabs, Dynacare Valley Medical Laboratories, as necessary for the purposes of administering the candidate’s participation in the program, facilitating the evaluation process, funding verification, entitlement, disbursement of financial stipends, grants, reimbursement or waiver programs, statistical analytics, surveys, potential recruitment, employment, and other such related purposes.

I certify that all of the information that I have provided in this form is accurate and complete.

I certify that all of the information that I have provided in this form is accurate and complete.

I understand and agree that if I make a false or misleading statement or representation with respect to my application, I will not be eligible for the IEMLT Credential Assessment and Education Bursary.

I understand and agree that if I make a false or misleading statement or representation with respect to my application, I will not be eligible for the IEMLT Credential Assessment and Education Bursary.

I consent to the use of my Personal Information for the purposes listed above.

I consent to the use of my Personal Information for the purposes listed above.

I understand that my Personal Information may be shared in the future without my express consent pursuant to a valid exception under the appropriate privacy legislation.

I understand that my Personal Information may be shared in the future without my express consent pursuant to a valid exception under the appropriate privacy legislation.

You are free to withdraw your consent to any continued use of your Personal Information at any time. However, we require your Personal Information to determine funding eligibility and requesting the withdrawal will make you ineligible to receive any bursary or funding. Should you withdraw your consent, your Personal Information will be securely destroyed as soon as is reasonably practicable.

If you have any questions regarding the collection, use, access, retention and/or destruction of your Personal Information please contact mltbursary@healthmatchbc.org.

Signature

Type your full name

Verification of Signature

I attest that my typed name in the signature line above is equivalent to my legal signature.

Date of Signature