© ANZ National Certification Learn More Booklet

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Attachment 1 - Employment Verification Form, Page 1 of 2

CERTIFIED CASE MANAGER™ - EMPLOYMENT VERIFICATION FORM

The information being sought in this form is for the purpose of verifying the employment details of the named “Employee” (past or present) by your Organisation or Company. The “Employee” is seeking national recognition as a Certified Case Manager™, i.e. Certified Practising Case Manager™ or Certified Case Manager (Non Practising)™ . Pursuant to this application the “Employee” must submit evidence of their FTE vocational practice experience to the CMSA in accordance with the minimum pre-requisite requirements for the said application. It is important to know in completing this form for the “Employee”, and on behalf of your Organisation or Company, you may be contacted by a representative of the CMSA to either clarify or verify any details as provided within this form. Please complete, print and sign this form prior to returning it to the “Employee” . Information must be typed into this form. Handwritten versions of the form will not be accepted by the CMSA. I am providing employment information with the full knowledge and consent and as requested, for and on behalf of Title (Dr, Prof, Mr, Mrs, Ms): SURNAME:

TO THE EMPLOYER

“ Employee ” details

GIVEN/FIRST name:

“Employee” address: “Employee” position title within your Organisation or Company: If more than one please list. Practice area of “ Employee ” (as it relates to case management): (e.g. academic, advisor, case manager, consultant, clinician, educator, executive, manager, mentor, policy planner, practitioner, supervisor, researcher etc) “Employer” Organisation or

Company Name: Postal address: Suburb: State/Territory (Australia): Town/City (New Zealand): Postcode: Country:

COPYRIGHT © 2017 Case Management Society of Australia and New Zealand and Affiliates (CMSA)

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

C E R T I F I E D C A S E M A N A G E R A U S T R A L I A & N E W Z E A L A N D

The Case Management Society of Australia and New Zealand and Affiliates (CMSA) Certification sets the benchmark of excellence in case management. Certified Practising Case Managers™ (CPCM) and Certified Case Managers (Non Practising)™ (CCMNP) adhere to the CMSA National Standards and National Code of Ethics for Case Management and are recognised for their advanced education, experience, knowledge and skills by their colleagues, consumers and employers.