csep certified member leave of absence application

CSEP CERTIFIED MEMBER LEAVE OF ABSENCE
APPLICATION
Renewal Year: March 31, 2015 to March 31, 2016
This form is intended for individuals who hold a CSEP Certified Personal Trainer® or CSEP Certified
Exercise Physiologist® certification expiring March 31, 2015 who are applying for a Leave of
Absence.
CSEP-CPTs and CSEP-CEPs who are registered with CSEP may, upon approval from CSEP, take a
Leave of Absence that is effective for CSEP's current membership year (April1-March31) only. More
information about the LOA policy can be found at www.csep.ca/LOA.
1. Contact Information
Name: ______________________________ Surname: _____________________________________
Address: _________________________________________________________________________
City: _______________________________ Province: ________ Postal Code: __________________
Phone:
Home: (_____) ______ - _________ Work: (_____) ______ - ________
Mobile: (_____) ______ - _________
Member ID: _________________________ E-mail: _______________________________________
Preferred Language:
☐ English
☐ Français
I hereby acknowledge that the email address that I have provided to CSEP
may be used for communication purposes as long as I am a member of CSEP
(if no choice is selected, it is automatically deemed that you agree)
☐ Agree
☐ Disagree
2. Leave of Absence applied for:
o
o
o
Maternity and Parental Leave
Personal Emergency Leave
Family Medical Leave
o
Other: ________________________________________________________________________
* please note: CSEP certified member with the Canadian Forces Morale and Welfare Services must contact Christine Charron
([email protected]) for leave of absence requests.
Supporting Documentation
Please provide documentation to support your application. This would be any documentation that
was provided in order to be approved for Employment Insurance, or a letter from your employer
confirming your leave of absence from work.
Canadian Society for Exercise Physiology | Société canadienne de physiologie de l’exercice
#370 – 18 Louisa St. Ottawa Ontario K1R 6Y6 | www.csep.ca
CSEP CERTIFIED MEMBER LEAVE OF ABSENCE APPLICATION - MARCH 31, 2015 TO MARCH 31, 2016- PAGE 2 OF 2
o
Documentation attached _______________________________________________________
o
Documentation attached _______________________________________________________
o
Documentation attached _______________________________________________________
Expected date of return to practice ____________________________________________________*
* members returning to practice before this date may be required to pay additional fees.
3. Leave of Absence Fee
Renewal Fee
o CSEP-CPT
o CSEP-CEP
$115
$140
Tax (GST/HST)
o ON, NB, NL – 13%
o PEI – 14%
o NS – 15%
o AB, BC, MB, NT, NU, QC, SK, YT – 5%
_________
GST Reg. Nº R121749667
Total:
_________
4. Payment
☐ Cheque or Money Order payable to the Canadian Society for Exercise Physiology enclosed
☐ VISA
☐ MASTERCARD
☐ AMERICAN EXPRESS
Cardholder name: _____________________________________
Card number: ________________________________________
Expiry date (mm/yy): _____ / _____
CVD# ________
Authorized Signature: _________________________________
Send us your completed form with payment:
By post:
CSEP/SCPE
370 - 18 Louisa St
Ottawa, ON K1R 6Y6
By fax: 613-234-3565
By e-mail: [email protected]
For questions about certification renewal, contact the national CSEP office at 1-877-651-3755 x221.
CSEP Certified Personal Trainer® and CSEP Certified Exercise Physiologist® are registered trademarks of
the Canadian Society for Exercise Physiology.
v.2015-01-26
Canadian Society for Exercise Physiology | Société canadienne de physiologie de l’exercice
#370 – 18 Louisa St. Ottawa Ontario K1R 6Y6 | www.csep.ca