Application Leave of Absence Name* First Last Phone* Email* Registration Number* Request Date of Leave* Month123456789101112 Day12345678910111213141516171819202122232425262728293031 Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 End Date of Leave (max. 12 months)* Month123456789101112 Day12345678910111213141516171819202122232425262728293031 Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Type of Leave of Absence Requested Health Reasons (Please attach Medical documentation) Military Employment Change/interruption Jury Duty Bereavement Return to School Maternity/Paternity Other (describe below) Other Please describe your reason for a request for a Leave of Absence. Fee* Online PayPal Total $ 0.00 CAD Application Declaration* I understand that I must notify the College before I return to ANY active VR/VE employment and must activate my registration status to Practicing. 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 it is recommended I maintain E&O/Liability insurance 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.
