Certified Senior Advisor - Canadian Academy of Senior Advisors Inc

Application for Certified Senior Advisor (CSA)® Form

Please complete and submit this application and disclosure questionnaire, or print then mail or fax this print friendly form to us with appropriate payment details.

* Denotes required fields.

Course

Course:

Fast

City:

Edmonton

Date:

2010-05-11

Personal

*First Name:

*Last Name:

*Formal Name as you would like it to appear for your certificate:

Current Designations:

If your industry requires you to be licensed, are you licensed in another province?

*How did you hear about CSA?

Name of CSA Who Referred You?

Business

*Job Title:

Company Name:

*Address 1:

Address 2:

*City:

*Province:

*Postal Code:

*Services Offered: Please check the services you offer below.
This will be entered into your website listing when you become a CSA. If you do not wish to be listed under our 'Find a CSA' page, please indicate so by checking the box below.
DO NOT list me on your 'Find a CSA' 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

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 CSA' page. If you do not wish to be listed under our 'Find a CSA' page, please indicate so by checking the checkbox above the Services area.

City 2 :

City 3 :

City 4 :

City 5 :

City 6 :

City 7 :

City 8 :

Mailing Address

*Address 1:

Address 2:

*City:

*Province:

*Postal Code:

Contact

*Business Telephone:

Toll Free Telephone:

*Home Telephone:

Mobile Telephone:

Fax:

*Email Address:

Alternate Contact Person (optional):

Alternate Contact Person's Email (optional):

Website Address:

http://

*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

CASA Terms of Designation

a) I understand that permission to use the mark Certified Senior Advisors (CSA)® and related marks is valid for a period of one year from the date of my CSA designation assuming I remain a member in good standing. If I fail to comply with requirements to renew my CSA 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 CSA.

b) I understand and agree that the CSA Board of Standards has the absolute and unrestricted right to revoke my CSA designation, including any rights I may have to use the marks, if it finds that I have failed to comply with the CSA Code of Professional Responsibility.

c) In consideration of the designation granted, I agree that neither the CSA Board of Standards, nor CASA, 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 CSA Board of Standards and CASA from any liability for such actions or omissions.

d) I will fulfill any ongoing continuing education required to maintain my CSA 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 CSA, I also agree to comply with all standards and requirements that may be issued from time to time, including usage of CASA’s proprietary mark(s), including Certified Senior Advisor (CSA)®.

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 Correspondence 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 Correspondence 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.

Correspondence 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 Correspondence Course. All materials must be returned in its original condition.

CASA 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 correspondence), 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 Canadian Academy of Senior Advisors (“CASA”) TERMS OF DESIGNATION and I also agree to the above CANCELLATION POLICY.

Yes