© Certification Application Guidelines

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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: GIVEN/FIRST name:

TO THE EMPLOYER

“ Employee ” details

“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:

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

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 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

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