First Name/ Prénom * Last Name / Nom * Address / Adresse * City /Ville * Province * Postal Code / Code postal * Country / Pays * Phone / Téléphone * Email / Courriel * First Attempt / Premier essai * Yes / Oui No / Non If no, please indicate the number of attempts. / Sinon, veuillez indiquer le nombre d'essais. Note: When tallying a candidate’s attempts at the CMRE, all the previous attempts in all jurisdictions must be counted. If it is discovered that all previous CMRE attempts are not disclosed on the CMRE Registration Form, the candidate will not be allowed to attempt the exam again. Not disclosing all previous attempts could impact the candidate’s registration, or application for registration, in the jurisdiction where they intend to practise. Special Accommodation / Requête d'accommodement (adaptation) Requests for special exam accommodation must be received by the exam registration deadline and must be accompanied by supporting documentation. Contact admin.cmre@cmrc-ccosf.ca to obtain the form. Are you requesting special assistance or accommodation on the day of the exam? Yes / Oui No / Non Eligibility / Admissibilité * Please indicate by what means you are eligible to write the CMRE: Bridging or Assessment Program Approved Canadian Baccalaureate Midwifery Education Program Name of program / Nom du programme * Exam Site / Examen en ligne (de la maison ou d'un centre d'examen) * This is an ONLINE EXAM. Candidates can complete the exam from home/other private location with live remote proctoring or in a designated test centre. Please identify your choice below and note that changes are not possible. Note that the live remote proctoring option requires the candidate to have a reliable and stable Internet connection, as well as being responsible for doing system checks prior to the exam. Note that test centres may have specific rules/restrictions that CMRE candidates must adhere to. From a private location using live remote proctoring In a physical test centre Preferred City or Location / Ville préferée * Time Zone for Exam / Fuseau horaire pour l'examen Time zone you will be in for remote proctoring. Fuseau horaire pour la journée de l'examen. Newfoundland Time (GMT-2:30) Atlantic Time (GMT-3) Eastern Time (GMT-4) Central Time (GMT-5) Mountain Time (GMT-6) Pacific Time (GMT-7) Payment Option / Paiement * CMRE Fee / Frais d'examen $945 INTERAC e-transfer to tracy.murphy@cmrc-ccosf.ca Cheque payable to Canadian Midwifery Regulators Council 303-21 St. Clair Ave East, Toronto ON M4T 1L9 Results / Résultats * I consent to have my results sent to the midwifery regulatory authority in the following jurisdiction(s) / Je consens à ce que mes résultats soient envoyés à l'organisme de réglementation de la profession de sage-femme dans la (les) jurisdiction(s) suivante(s) BC YT AB NT SK MB NU ON QC NL NB NS PE Candidate Statement / Déclaration du candidat * Prior to beginning the exam, candidates must sign a statement of understanding that addresses the confidential nature of the CMRE, exam invigilation, cheating, and the potential impact of testing irregularities. This information is also available on the Registration Exam page of the CMRC website. Unless an accommodation has been approved, candidates are allowed to have only water in a clear container at the exam. No other food or beverages are permitted. Avant de commencer l'examen en ligne, les candidats doivent signer une déclaration/énoncée de compréhension. Cette déclaration traite la nature confidentielle de l'examen, la surveillance de l'examen, la tricherie et les irrégularités provées our présumées. Ces renseignements sont également disponibles sur la page de l’examen d’inscription du site Web du CCOSF. Sauf s'il y a une adaptation approvée, les candidats peuvent consommé seulement de l'eau dans une bouteille d'eau transparente à l'examen. Aucun autre aliment ou boisson n'est permis. Please check here to acknowledge that you will abide by exam rules and regulations set out in the Candidate Statement of Understanding and on the CMRC website. Veuillez cocher cette case pour confirmer que vous respecterez les règles de l’examen énoncées dans la déclaration d’intention du candidat et sur le site Web du CCOSF.