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:
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signature
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Continuing Education Credit Application Form
CCPA_CECAPP_04_2018
Title of event/course
(ignore if submitting for
professional involvement or
volunteer work)
Description of event/Summary of activities: Include brochure or website of the event if applicable.
Start Date (MM/DD/YY) End Date (MM/DD/YY) Days: Hours:
Learning Outcomes: In your own words; what did you learn? How have your knowledge, skills or
competencies been enhanced? Please explain how each activity has contributed to your professional
development.
If attending an event, please include the following information regarding the leader and location:
Leader's Name and Qualifications:
Sponsor:
City: Province/State:
Proof of Attendance
It is recommended that you take this form with you to the event you are attending and have the workshop
leader sign this form upon completion of the workshop. If this is not possible, please submit a certificate of
attendance with your application. Please note: Receipts or Registration is not a valid proof of attendance
Signature or stamp of the educational event Leader/Speaker or Sponsor. (Please note that presenters can't
sign it themselves to prove attendance):
*Signature: Print Name:
Schedule A: Independent Study/Peer Study/ Workshop/Conference/Webinar/ Graduate Coursework/
Presentation Development or Delivery/ Professional Involvement/Volunteerism
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signature
click to edit
Continuing Education Credit Application Form
CCPA_CECAPP_04_2018
Schedule B: Receiving Supervision
Nature of supervision:
What did you learn? How have your knowledge, skills or competencies been enhanced? Please explain
how the activity has contributed to your professional development and/or contributes to the advancement
of the counselling profession. Please include a log of hours.
Start Date
(MM/DD/YY)
End Date
(MM/DD/YY)
Days: Hours:
Supervisor Information
Name Years of Clinical Practice
Email Phone Number
Professional Designation/Membership
Supervisor Signature
Education
click to sign
signature
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Continuing Education Credit Application Form
CCPA_CECAPP_04_2018
Schedule C: Scholarly/Applied Writing or Thesis/Dissertation Writing
*Please note that a copy of your writing must be included as part of the application for continuing education
credits.
Title of article/book
APA-style
Reference
Link to online
version
If you are including a copy of the book, would you like it returned to you?
Yes No
Hours and date of writing:
Start Date MM/DD/YY END Date MM/DD/YY Number of hours invested
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