Application for Extension of CEU Period The non-refundable CEU Extension Application Fee is $100.00 + Provincial taxes. If this application is received 15 days prior to your CEU submission date, your registration status will remain in good standing. If this application is received past your CEU submission date, your registration status will be changed to Administrative Suspension, and will remain as such until the application for extension has been reviewed and processed. Regardless of the date the application is received, you will have up to 60 days from the CEU submission date to submit all outstanding CEU’s. If all outstanding CEU’s are not received by 60 days past your CEU submission date, your registration will be suspended. Name* Certification and Number* Year and Month Certified: example 2014 January. Home Address City Province Postal Code Phone Fax Email Employer* Employer Address* Work Phone Work Fax Work Email Position Title Number of Domain CEUs Collected to date* Number of Ethics CEUs Collected to date:* End Date of Present CEU Period:* Reason for requesting extension for CEU accumulation (please describe): Please upload information documenting Employment Parental Leave Please upload information to document Medical/Compassionate Leave for additional CEU extension Only 1 application for CEU extension is allowed per 2-year CEU period. Failure to submit all required CEU’s by 10 days prior to the extension date will result in suspended registration and further penalties. Click the appropriate payment box. There is an administration fee of $15.00 for manual form submission and payment by cheque, money order or bank draft. PayPal ($100.00 + Tax) Application Declaration: I hereby verify that the information submitted for this application accurately documents my request without impinging on my right to Privacy. I understand that providing false information will result in immediate withdrawal of my application and could result in disciplinary action. I hereby declare that the information given in this application is, to the best of my knowledge, true, correct, and complete in every aspect and that I am the applicant.* By clicking here you accept the Application Declaration and all information provided to be true.