Application or renewal – Clinician/Healthcare Professional form

Before completing this form, make sure you have all the necessary information/documents.

Identification
Click the type of demand*
- Nomination
- Renewal
Last name*
First name*
Title*
Specify (other title)*
Institution*
What is the name of your clinical program?*
Maximum of 4 answers (one answer per line).
Phone number*
Email*
Education
Training for the current position. The training courses can be viewed on your Clinicians/Healtcare member page on the CRIR website.

Formations

Formation	Discipline/University	Year

Areas of expertise
Areas of expertise (specialization)*
Professional experiences
Professional experiences*
Institution Department Date
Research interests
List of research interests*
Please indicate here your interest in adaptation-rehabilitation research.
Collaborations
Collaborations
Name of researcher Project title
Additional comments
Interest*
Please indicate here your interest in remaining at CRIR, if this is a renewal application.
Publications / congress presentations
Publications / congress presentations*
Other accomplishements
Other accomplishements*
Support
Name of principal collaborating researcher*
E-mail of principal collaborating researcher*
Name of your immediate superior*
E-mail from your immediate superior*
Use this section to attach documents
Drop files here or

Max. file size: 128 MB.
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Name
This field is for validation purposes and should be left unchanged.

Funding

Institution	Department	Date

Name of researcher	Project title