CVRP Renewal Application Form

Certificate Class and Number:*

Renewal Month*

First Name:*

Middle Name:

Last Name:*

Home Address:*

Apartment, Suite or Unit #:

City, Town, or Region:*

Province/State

Postal Code/Zip Code

Home Phone*

Personal Cell Phone*

Format (000)000-0000

Personal Email:*

Current Employer:*

Your Current Position and/or Title:*

Employer Address:*

City, Town or Region:*

Province/State

Postal Code/Zip Code

Work Phone Number (enter 0's if not applicable):*

Format (000)000-0000

Work Cell Number (enter 0's if not applicable):

Format (000)000-0000

Work Email:*

Mandatory Continuing Education

Already Submitted
Submission with Renewal
Not required with this renewal

Annual Fee Payment Method*

1 Certification $285.00 plus applicable taxes
2 Certifications $385.00 plus applicable taxes
More than 2 Certifications $400 plus applicable taxes
If annual renewal is a manual payment please add $15.00 administrative fee.

Application Declaration:

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

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 the College, including immediate suspension of my certification of registration. I confirm that it is my obligation to notify the College within 30 days in the event that any of my information changes. I understand that misrepresentation of this renewal information in any way may result in cancellation of my registration status.

I confirm that in the past year, I have not been charged or 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 regulated field, on the grounds of professional misconduct in Canada or elsewhere.

*The following questions must be answered.

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

No
Yes

If yes, please explain:

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?*

No
Yes

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?*

No
Yes

If yes please explain:

I agree to annually review the College Standards of Practice, Code of Ethics, and By-Laws. I undertake to abide by all of the rules, regulations, standards and policies of the College (the Governing Rules and Regulations”). I understand that my registration in the College is voluntary and that by becoming a registrant, I consent to the College acting as my professional self-regulating body.

I agree to abide by the provisions of the Governing Rules and Regulations and I recognize that the College has the right to limit or terminate my registered status under the College’s Bylaws, Policies or Code of Professional Conduct.

As a voluntary registrant, I hereby release the College from all liability for any act of negligence or want of ordinary care on the part of the College and or any of its agents. In consideration of my registration in the College, I waive, release, and discharge College 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 College and its authorized representatives, for any acts, communications, or decisions regarding the processing, consideration, and maintenance of my registration 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 bi-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 40 (34 credits from Core Domain Learning and 6 Ethics credits) in a 2 year period.

I hereby declare that the information given in this application and any attached/forwarded document(s) is, to the best of my knowledge, true, correct, and complete in every respect and that I am the College Registrant applying for annual certification renewal.

*

By checking the box, I confirm that I have read, understand and agree with terms and conditions outlined above.

Date of submission*

MM

DD

YYYY

Check here if employed by WSIB and submit form only