Continuing Education Credit Application Form
CCPA_CECAPP_04_2018
First & Last Name (Print/Type):
CCPA Member ID (If you are not a member, a cheque must accompany this application):
Job Title & Organization:
Mailing Address:
City:
Prov./State:
Postal Code:
Phone: Email:
*Applicant's Signature:
“I certify that I participated in the event listed below and achieved the criteria necessary to obtain the
Continuing Education Credits assigned to this event”
Members of CCPA: No cost to submit CEC applications. Transcript may be requested yearly at no cost.
Non-Members: $30 per application. Additional $30 for issue of CEC transcript to third party.
Types of Continuing Education Credit
(check one)
Instructions for completing this form
Complete Schedule A.
Complete Schedule A. Proof of Attendance (ex.
signature, certificate, transcript, etc).
Complete Schedule A. Attach confirmation of
presentation (ex. signature, program, etc)
Complete Schedule A. Attach activity log.
Complete Schedule B. Attach statement signed by
supervisor, log of dates and duration of sessions.
Complete Schedule C. Attach copy of thesis/
dissertation or link to online version.
Receiving Post-Graduate Supervision
Professional Involvement/Volunteerism
Presentation Development or Delivery
Workshop/Conference/Webinar Graduate
Coursework
Independent Study/Peer Study
Thesis/Dissertation Writing Scholarly Writing/
Applied Writing
Options for submitting a completed form:
1. Save and email form to cec@ccpa-accp.ca.
2. Print and fax form to: 613-237-9786
3. Print and mail form to:
202 - 245 Menten Place, Ottawa, ON, K2H 9E8
Please use one form from each event. FORM MUST BE SIGNED.
Please submit the first page of this form along with the appropriate schedules. Only submit the
schedule required for your event. Please allow 2-6 weeks for review.
Fees:
click to sign
signature
click to edit
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