Candidate Name (required) Candidate Email (required) Candidate Address(required) Candidate City (required) Candidate Province (required) ---ABBCMBNBNLNSNTNUONPEQCSKYT Candidate Postal Code (required) Candidate Phone Number (required) Month & Year Teacher Training Completed (optional): Month ---JANUARYFEBRUARYMARCHAPRILMAYJUNEJULYAUGUSTSEPTEMBEROCTOBERNOVEMBERDECEMBER Year ---20142015201620172018201920202021202220232024202520262027202820292030 Assessment Location Requested: ---West 2022-H1East 2022-H1West 2022-H2East 2022-H2West 2023-H1East 2023-H1West 2023-H2East 2023-H2 Your mentor must hold must hold a Level 2 certificate or higher. Mentor Name Mentor Certification Level ---Level 2Level 3 Mentor Email Address Note: Size of files uploaded must be less than 3MB and one of the following file types: gif png jpg jpeg pdf msg bmp Upload copy of Associate Member Receipt Upload copy of Assessment Fee Receipt Upload passport type photograph Upload answers to 12 QUESTIONS Optional notes/comments: I affirm my intention to sit the assessment and give consent that my application for assessment will be shared with the assessment team and the results of my assessment will be sent by email to my mentor for review and consultation. NOTES: 1) Upon submission of this form, your mentor will receive an email (copied to you) to complete your provisional recommendation. 2) Once all documentation is complete, the candidate’s placement will be confirmed in the assessment applied for on a first-come basis (4-6 candidates maximum per assessment). 3) Final recommendation is due four months prior to the assessment date.