Designated Medical Practitioner Handbook

Appendix XVIII: DMP’s Acknowledgment of
Having Read the Handbook

I acknowledge that I have received and read the 2009 Edition of the CIC Handbook for Designated Medical Practitioners.

I have questions or require assistance in interpreting some aspects of the handbook.

YES ( )            NO ( )

_______________________________________      
(Print Name)

Date: _______/_____/_____
          YYYY    MM     DD

_______________________________________
(Signature)

_______________________________________
(Stamp #)

_______________________________________

_______________________________________
(Address)

Thank You,

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