1243 Islington Avenue, Suite 501
Toronto, Ontario M8X 1Y9
P : 416 234 8800 | F : 416 234 8820
www.alliancept.org
Form C – Educational Credential and Qualifications Assessment
Written Component – Declaration of Identity Form: Instructions
You must send your Declaration of Identity with your first application for the exam (i.e., the first time you apply for
the Written Component). You must also send a Declaration of Identity if your last exam was before 2011. (The Declaration of Identity was a new requirement in 2011.)
If you have already completed a Declaration of Identity for credentialling, you do not have to do another one. We will
get your Declaration of Identity from the credentialling department.
Please note that the self-study module declaration is not the same as the Declaration of Identity form. If you are
unsure about whether you have previously completed the Declaration of Identity, please contact CAPR.
You must complete the Declaration of Identity and sign it in the presence of a notary public. A notary public is a
person who is authorized by the province or country in which you live to administer oaths (swear to the truth of a
statement). To have your documents notarized, you will need to show the original of each document to the notary
public. The notary public will complete Section 2 of the Declaration of Identity form.
You must send us two identical photographs. These photographs must:
• Be passport size and passport quality
• Be in colour
• Show you alone, with your face clearly visible, and eyes open
• Be taken within the past 6 months
You must attach one copy of the photograph to your Declaration of Identity. The notary public will stamp or seal
over the photograph.
You must send the other copy of the photograph with the Declaration of Identity. On the back of this second photograph, you must print your name, print the date the photograph was taken and sign.
The Declaration of Identity is valid for five years from the date on the form. If you change your appearance or your
name within that time, you must send a new Declaration of Identity form.
Your Declaration of Identity form must still be valid when you attempt an administration of the PCE. We use the
photographs you send to prepare your Entry Certificates for the Written Component and the Clinical Component.
If you do not match your Entry Certificate photograph, you may not be able to take the exam.
1243 Islington Avenue, Suite 501
Toronto, Ontario M8X 1Y9
P : 416 234 8800 | F : 416 234 8820
www.alliancept.org
FORM C – WRITTEN COMPONENT – DECLARATION OF IDENTITY
I,
, declare that I am the person named on this document and the
photograph attached to this document is my photograph.
Section 1 – Applicant
Stamp or seal of the Notary
Public must cover a portion
of the attached photograph
and a portion of this form.
Photo
By signing the Section 1 of the Declaration of Identity document you certify that the photograph attached herein is your photograph which was taken within the past six (6) months.
Full Legal Name of Applicant (Print):
Last Name(s)/Surname(s):
First Name(s)/Given Name(s):
Middle Name(s):
Date of Birth of Applicant: Day: Month: Year: Signature of Applicant:
Section 2 – Notary Public
Stamp or seal
of Notary Public
I certify that I have checked the identity document(s) and I have verified the identity and the legal name of this person and that this person has signed before me on:
Day: Month: Year: At:
Name:
Signature:
Address:
Telephone:
Email:
The Notary Public’s contact information is required to allow us to verify the applicant’s information, if necessary
A Notary Public must officially certify this document.