© Certification Application Guidelines

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Attachment 3 - Professional Training and Development (PTD) Form B - Page 2 of 2

Total time of all PTD activities as claimed on Form A: Please record the total sum of hours and/or minutes for all PTD activities you have recorded and claimed on each Form A. Please note you are required to have accumulated a minimum of 72 hours of PTD in the last 3 years to support your application. 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 must have accumulated a minimum of 72 hours of PTD activities as a pre-requisite to be eligible to apply for recognition as a Certified Case Manager™ pursuant to my nominated vocational pathway.

Signature:

_________________________________________

Date:

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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