© 2013 Associate Fellow Application Guidelines

12

Attachment 1 - Employment Verification Form, Page 2 of 2

“Employer” Job Title: “Employer” Business Phone:

“Employer” Mobile: “Employer” Email:

Date of “Employee” appointment: Is the “Employee” presently employed with your Organisation or Company?

Yes No Please provide end date of employment contract:

Average hours of “Employee” per week ?

hours

“Employee” FTE equivalent of hours for term of employment? FTE are based on 38 hours per week over 48 weeks. Do you know of any information that may give rise to concern of the “Employee” that may disqualify the “Employee” as being a fit and proper person for recognition by the CMSA as an Associate Fellow? Total “Employer” Comments (optional): Please add any additional information or comments in relation to the “Employee” that you consider relevant for the attention of the CMSA. “Employer” Declaration:

Yes Please provide details: No

I solemnly and sincerely declare that the information I have provided is true and correct to the best of my knowledge and belief. I solemnly and sincerely declare that I have not omitted any information that may give rise to concerns by the Case Management Society of Australia and New Zealand (CMSA) as to the app ropriateness of the “employee” receiving recognition as an Associate Fellow nor unduly challenge the veracity, integrity or fidelity of the Society, its members and the profession of Case Management.

“Employer” 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

Associate Fellow Members (AFCMSA) 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.