© 2013 Fellow Application Guidelines

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Attachment 2 - Professional Training and Development (PTD) Form A - Page 2 of 2

Supporting evidence of the PTD activity: Please state the evidence that you can provide, if requested by the CMSA, of this PTD activity Total time of PTD activity:

In hours and/or minutes. Comments (optional):

Please add any additional information or comments in relation to this PTD activity that you consider relevant for the attention

of the CMSA. Declaration:

I solemnly and sincerely declare that the information I have provided is true and correct to the best of my knowledge and belief. I acknowledge that I may be required upon request by the CMSA to provide supporting evidence of the PTD activity claimed within this form. I have read the CMSA Fellow Application Guidelines and checked that this PTD activity is a recognised and approved PTD activity by the CMSA as recorded within the said Guidelines.

Signature:

_________________________________________

Date:

C A S E M A N A G E M E N T S O C I E T Y O F A U S T R A L I A & N E W Z E A L A N D 1 9 9 6

Fellow Members (FCMSA) of the Case Management Society of Australia & New Zealand (CMSA) adhere to the CMSA National Standards & National Code of Ethics for Case Management in all their day-to-day professional interactions with colleagues, the community, clients & /or representatives, key stakeholders & employer thus contributing to the veracity, integrity & fidelity of the profession of case management.