| Certified Professional Consultant on Aging (CPCA)®
Application Form |
Cost: $195 (Membership Dues), plus one time $50 administrative fee, plus applicable taxes.
Please
complete and submit this application
and disclosure questionnaire below. Secure credit card processing by Moneris.
* Denotes required fields.
|
| Personal |
| *First
Name: |
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| *Last
Name: |
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| *Formal
Name as you would like it to appear
for your certificate: |
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| Current
Designations: |
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| If your industry requires
you to be licensed, are you licensed
in another province? |
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| *How
did you hear about CPCA? |
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| Business |
| *Job
Title: |
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| Company
Name: |
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| *Address
1: |
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| Address 2: |
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| *City: |
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| *Province: |
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| *Postal
Code: |
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*Services
Offered: Please check the
services you offer below.
This will be entered into your website
listing when you become a CPCA. If
you do not wish to be listed under
our 'Find a CPCA' page, please indicate
so by checking the box below.
DO NOT list me on your 'Find a CPCA'
page |
| Financial
Services |
Financial Planning
Insurance
Investment
Tax Planning
Estate Planning
Accountant |
Retirement Planning
Long Term Care
Group Benefit Plans
Banking
Mortgage Broker
Gift Planning |
| Health
Care Services |
Home Care Provider
Assisted Living and/or Nursing Care
Home Services
Pharmacy
Medical Devices/Equipment |
Health Care Admin/Mgt
Therapy (OT/PT/RT etc.)
Palliative Care
Counsellor |
| Social Services |
Travel and Tourism
Legal Services
Notary Public
Senior Citizen Organization
Retirement Home Services
Marketing and Advertising
Move Organizer
Mediator
Real Estate Services |
Alternative Housing Needs Specialist
Funeral Services
Clergy
Media (new)
Retail (new)
Consultant
Charity
Conflict Resolution |
| Additional
Service Locations |
You may add up to 7 additional cities
where you provide the above services.
Like "Services", these additional
cities allow you to be found when
someone uses our 'Find a CPCA' page.
If you do not wish to be listed under
our 'CPCA' page, please indicate
so by checking the checkbox above
the Services area. |
| City
2 : |
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| City 3 : |
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| City
4 : |
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| City 5 : |
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| City
6 : |
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| City 7 : |
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| City
8 : |
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| Mailing
Address |
| *Address
1: |
|
| Address
2: |
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| *City: |
|
| *Province: |
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| *Postal
Code: |
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| Contact |
| *Business
Telephone: |
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| Toll
Free Telephone: |
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| *Home
Telephone: |
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| Mobile
Telephone: |
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| Fax: |
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| *Email
Address: |
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| Alternate Contact
Person (optional): |
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| Alternate
Contact Person's Email (optional): |
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| Website
Address: |
http://
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| *Disclosure
Questionaire |
| 1. Have you been accused or convicted
of a felony or criminal offence? |
Yes
No |
| 2. Are you currently
or have you within the past five years
been a defendant or respondent in
any criminal proceeding relating to
your professional or business conduct? |
Yes
No |
| 3. Are you now or have you within
the past five years been a defendant
or respondent in a civil action, which
includes but is not limited to a lawsuit,
arbitration, or mediation relating
to your professional or business conduct? |
Yes
No |
| 4. Have you had
a license, permit, certificate, registration,
or membership denied, suspended, revoked,
or restricted within the past five
years, or have you had an application
withdrawn for cause within the past
five years? |
Yes
No |
| 5. Have you ever been censured,
fined, or reprimanded by a province
or federal licensing or regulatory
body? |
Yes
No |
| 6.
Have you been censured, fined, or
reprimanded by any professional credentialing
organization of which you are a member? |
Yes
No |
If
you answer "Yes" to any
of these disclosure questions,
you must set forth the principal facts
relating to each incident below
|
Age Friendly Business®
Terms of Designation
a) I understand that permission to
use the mark Certified Senior Advisors
(CPCA)® and related marks is valid
for a period of one year from the
date of my CPCA designation assuming
I remain a member in good standing.
If I fail to comply with requirements
to renew my CPCA membership at the
end of the first year and annually
thereafter, I agree to immediately
cease use of the mark(s) and to not
hold myself forth as a CPCA.
b) I understand and agree that
the CPCA Board of Standards has the
absolute and unrestricted right
to revoke my CPCA designation, including
any rights I may have to use the
marks, if it finds that I have failed
to comply with the CPCA Code of Professional
Responsibility.
c) In consideration of the designation
granted, I agree that neither the
CPCA Board of Standards, nor Age Friendly Business,
its directors, officers, employees
and others acting on its behalf,
shall be liable to me for any actions
taken or omitted to be taken in
any official capacity or in the
scope of employment, except to the
extent that such actions or omissions
constitute willful misconduct or
gross negligence, and I hereby release
the CPCA Board of Standards and Age Friendly Business
from any liability for such actions
or omissions.
d) I will fulfill any ongoing continuing
education required to maintain my
CPCA designation.
My submission of this application
indicates my agreement to comply
with all rules and requirements
of the Canadian Academy of Senior
Advisors, Inc. If designated as
a CPCA, I also agree to comply with
all standards and requirements that
may be issued from time to time,
including usage of Age Friendly Business’s
proprietary mark(s), including Certified
Senior Advisor (CPCA)®.
Cancellation Policy
“Live” Class Cancellation:
Registrants who provide at least
one week’s notice, prior to
the start date of the “live”
class, may transfer to another "live"
class course, or to the Independent Study
Course at no additional cost. A
cancellation within one week of
a” live” class course, and a request to transfer to
another course, will result
in a catering fee of $160, plus
GST that must be paid at time of
cancellation. Cancellation without
transfer to another Live Class or
Independent Study Course will result
in a cancellation fee equal to 50%
of the tuition paid for the course.
All materials must be returned in
good condition.
Independent Study Class Cancellation:
Registrants can up-grade to any
live class and will be charged the
difference in the tuition. Registrants
who do not up-grade to a live class
and cancel will be charged a cancellation
fee equal to 50% of the tuition
paid for the Independent Study Course.
All materials must be returned in
its original condition.
Age Friendly Business® periodically reviews and updates
information in the study material
in order to keep the course current.
If new study material has been introduced
for any live class that a registrant
has transfered into, (this includes
transfers from Independent Study),
a fee of $100 plus GST will be charged
for the new study material and the
shipping thereof.
|
| *I
affirm that my answers to the above
questions 1 - 6 are true, I agree
to the above Age Friendly Business® TERMS
OF DESIGNATION and I also agree to
the above CANCELLATION POLICY. |
Yes |
| *When I become a CPCA, I agree to abide by the CPCA Code of Professional Responsibility. |
Yes |
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