© 2013 Associate Fellow Application Guidelines

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Attachment 4 - Referre Form 1 - Page 2 of 2

How long have you known the applicant? Please record approximate time in years and actual time in months if this period is less than 2 years. Please provide a comprehensive description, including your comments and observations, in relation to the vocational experience and performance of the applicant as it relates to their case management role (i.e. practical, managerial or theoretical) (150 – 200 words) Do you know of any information that may give rise to concern of the applicant that may disqualify the applicant as being a fit and proper person for recognition by the CMSA as an Associate Fellow? Comments (optional): Please add any additional information or comments that you consider relevant for the attention

Yes Please provide details: No

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 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 appropriateness of the applicant 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.

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.