CVRP CREDENTIAL LADDERING FORM

Date of Application*

Full Name*

First

Last

Current CVRP Credential & Registration Number:*

Date of Registration*

Address*

Address 2

City*

Province*

Postal Code*

Phone*

Cell Phone

Email*

Current Employer*

Current Position*

Field of Practice*

Address*

City*

Province*

Postal Code*

Phone*

Cell Phone*

Email*

I understand that the information provided on this application will be used for purposes of admission, registration, research and development, and other purposes consistent with the mandate of the College of Vocational Rehabilitation Professionals (CVRP).

I hereby verify that the information submitted for this application is accurate. I understand that providing false or incomplete information could result in action being taken by CVRP including immediate suspension of my certification of registration. I confirm that it is my obligation to notify CVRP within 30 days in the event that any of my information changes. I understand that submission of this application in no way guarantees a change in my certification of classification, and that misrepresentation of this information in any way may result in cancellation of my registration status.

I confirm that I have never been convicted of a criminal offence, for which I have not received a pardon that is relevant to my work as a Vocational Rehabilitation Professional.

I confirm that I have not been dismissed from employment or refused membership in a professional association or registration in a related field, on the grounds of professional misconduct in Canada or elsewhere.

*The following questions must be answered: Please use a separate sheet if more space is required.

*Regardless of outcome, have you ever been the subject or recipient of a complaint of professional negligence through membership in a professional association or registration in a related field?*

Yes
No

If yes please answer here*

*Are you now the subject of any type of investigation, inquiry or proceeding by a professional licensing body or professional association relating to your professional conduct, competence, capacity or any other aspect of your professional practice?*

Yes
No

If yes please explain*

*Are you aware of any facts, circumstances or situations which may reasonably give rise to a complaint other than noted above?*

Yes
No

If yes please explain*

I agree to annually review the Code of Ethics, Standards of Practice and By-Laws. I undertake to abide by all of the rules, regulations, standards and policies of the CVRP (the Governing Rules and Regulations”). I understand that my membership in the CVRP is voluntary and that by becoming a member, I consent to the CVRP acting as my professional self-regulating body. I acknowledge that my membership status in the CVRP is based on the CVRP’s Governing Rules and Regulations. I agree to abide by the provisions of the Governing Rules and Regulations and I recognize that the CVRP has the right to limit or terminate my membership status under the CVRP’s Bylaws, Policies or Code of Professional Conduct. As a voluntary member, I hereby release the CVRP from all liability for any act of negligence or want of ordinary care on the part of the CVRP and or any of its agents. In consideration of my membership in the CVRP, I waive, release, and discharge CVRP and their directors, officers, agents and members, their representatives, heirs, executors and assigns from any and all claims of liability. This agreement is binding upon my executors, heirs, and assigns. I hereby discharge and release from any liability, the CVRP and its authorized representatives, for any acts, communications, or decisions regarding the processing, consideration, and maintenance of my membership application and file. I hereby declare that I have current E&O insurance coverage for practicing as a Vocational Rehabilitation Professional. I understand that I must annually submit proof of approved Continuing Education Units (CEU’s) and must accumulate the total number of CEU’s required to maintain my level of certification. The maintenance level for CEU’s is currently set at 20 (17 credits from Core Domain Learning and 3 Ethics credits). I hereby declare that the information given in this application and any attached/forwarded documents is, to the best of my knowledge, true, correct, and complete in every respect and that I am the applicant.*

I AGREE

BY CHECKING I AGREE YOU AGREE TO THE TERMS OUTLINED IN THIS FORM.

Credential Laddering Fee of $185.00 (non-refundable). There is an administration fee of $15.00 for manual submission, cheque and money orders*

Online PayPal $185.00
Mail by Cheque/Money Order/Bank Draft $200.00