© 2013 Associate Fellow Application Guidelines

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Attachment 5 - Referre Form 2 - Page 1 of 2

ASSOCIATE FELLOW - REFEREE TWO (2) FORM

Your role as a “ referee ” is important in the substantiation of information provided by the “ applic ant” to the CMSA. Applicants seeking recognition as an Associate Fellow of the Case Management Society of Australia and New Zealand (CMSA) must provide full details of their referees. It is recommended by the CMSA that as a nominated referee you take the time to review and discuss the application and supporting documentation prior to it being submitted online to the CMSA. It is important to know that as a referee, you may be contacted by a representative of the CMSA to either clarify or verify any details or claims made by the applicant or yourself in support of the aforesaid application. Please complete, print and sign this form prior to returning it to the applicant. Information must be typed into this form. Handwritten versions of the referee form will not be accepted by the CMSA.

TO THE REFEREE

Applicant Name:

I am providing a professional reference for (insert full name):

Title (Dr, Prof, Mr, Mrs, Ms):

Referee 2 details

SURNAME:

GIVEN/FIRST name:

Position title: Organisation or Company name: Postal address: Suburb: State/Territory (Australia):

Town/City (New Zealand): Postcode: Country:

Phone: Mobile: Email: In what professional capacity do you know the applicant? (e.g. academic, advisor, case manager, colleague, consultant, clinician, educator, executive, manager, mentor, peer, policy planner, practitioner, supervisor, researcher etc)

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.