Application Form for Request for Non-Practicing Status Application for Non-Practicing Status To qualify for Non-Practicing Status, you must not be currently employed or practicing as a VR professional. It is recommended that you maintain E&O coverage as a non-practicing VR professional for your liability purposes. Name First Last Home Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone Fax Email Employer Information Former Employer Former Employer Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Former Employer Contact Employer Contact Email Current Position Start Date Month123456789101112 Day12345678910111213141516171819202122232425262728293031 Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Do you anticipate return to Practice* Yes No Return Date Month123456789101112 Day12345678910111213141516171819202122232425262728293031 Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Reason for Request for Non-Practicing Health Reasons Military Employment Change/interruption Jury Duty Bereavement Maternity/Paternity Return to School Other (describe below) Other Please enter other reason for Sabbatical Requested Current Designation CVRP(I) CVRP(P) CVRP CVRP(F) CVRP(D) CCVE CCVE(F) CCVE(D) CVRP Registration Number Year Certified: Length you have held valid certification (YEARS) Payment Type* Online PayPal $100.00 Paid by WSIB $100.00 Total $ 0.00 CAD Application Declaration:* By checking here I understand that I must notify the College before I return to ANY active VR employment as I must activate my registration status to Practicing. By checking here I understand that at it is a act of Professional Misconduct to work as a CVRP while registered as Non-practicing status. Application Declaration:* By checking here you agree to all the terms and conditions outline by CVRP in this application 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 understand that it is recommended that I continue to carry current E&O insurance coverage. I hereby declare that the information given in this application is, to the best of my knowledge, true, correct, and complete in every respect and that I am the applicant.