1- Personal Information :Name* First Middle Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email PhoneTime to Call : Hours Minutes AM PM AM/PM Basic Intensive Training Date: MM slash DD slash YYYY Instructor: Basic Practicum Date: MM slash DD slash YYYY Supervisor: 2- Application Process:Applicant Step 1: Complete this application, sign, date, and forward it to your Basic Practicum Supervisor. Practicum Supervisor: Complete co-verification, sign, date, and return to Applicant. Applicant Step 2: Remit Application to Organizer, along with your deposit made payable directly to Glasser Canada through www.glassercanada.ca or to organizer’s designation. Balance of fees are due at commencement of your Advanced Intensive Training. 3- Applicant's Self-Evaluation: – Specific area(s) in which I describe my performance as quality:Supervisor's Co-verification: – Specific area(s) in which I believe I need to emprove the quality of my performance:Supervisor's Co-verification: I have successfully completed the requarements of the Basic Practicum & believe I am ready to attend my Advanced Intensive Training.* i Agree
