Application Leave of Absence

Name*

First

Last

Residential Address*

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Personal Phone*

Personal Email*

Request Date of Leave*

End Date of Leave (max. 12 months)*

Type of Leave of Absence Requested

Health Reasons (Please attach Medical documentation)
Military
Employment Change/interruption
Jury Duty
Bereavement
Return to School
Other (describe below)

Other

Please describe your reason for a request for a Leave of Absence.

Current Designation

Registration Number*

Leave of Absence Application Fee $75.00 + applicable taxes

Price: $ 75.00 CAD

Fee*

Online PayPal

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 Leave of Absence status.

Application Declaration:*

By checking here, I 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 I must have current E&O insurance coverage and will maintain that coverage through-out my LOA. 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.