APPLICATION FOR REGISTRATION AS A SOCIAL WORKER CANDIDATE

(A complete application package will be sent upon receipt of this form)

Surname: ____________________________________________

Given Name: _________________________________________

Home Address: __________________________________________

Postal Code: _______ Phone: (____) ________ FAX: (____) _______

Email address: _____________________________

Name and Address of Employer:

______________________________________________________________________

Postal Code: _______ Phone: (____) ________ FAX: (____) _______

Email address: _____________________________

Social Work Education: (Name University, Degree(s):

______________________________________________________________________

Additional Courses and Standing:

______________________________________________________________________

Highest University Degree:

______________________________________________________________________

Professional Experience: (In chronological order for five consecutive years preceding date of application: give exact dates if possible; do not include student experience; include all types of professional experience, the last position listed should be your present position at the time of application; attach extra sheet for additional information if required).

POSITIONORGANIZATION PLACEFROM - TOIMMEDIATE SUPERVISOR

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Languages (spoken and written): ________________________________________

Community Involvement: ______________________________________________

Current ___ Previous ___ membership in a Professional Association: (Please indicate status of membership whether student or Associate member):

______________________________________________________________________

Please give the names of two persons (preferably R.S.W.'s who have direct knowledge of your social work practice), as references:

Name and Address: _______________________________________________________

______________________________________________________________________

Postal Code: __________

Name and Address: _______________________________________________________

______________________________________________________________________

Postal Code: __________

Have you ever been convicted of a criminal offence? Yes ___ No ___

If Yes - When and what was the nature of the offence?

______________________________________________________________________

______________________________________________________________________

Have you ever committed an act in violation of the Code of Ethics or the Social Workers Act?
Yes ___ No ___

If Yes, when and what Section of the Code or Act was violated?

______________________________________________________________________

APPLICATION AND PLEDGE:
I pledge and agree that, if registered as a Social Worker Candidate of the Nova Scotia Association of Social Workers, I shall act in accordance with the laws and by-laws pertaining thereto and shall promote the objects thereof so far as may be within my power and shall maintain the ethical standards of the profession of social work. In addition, I agree to adhere to the CASW Code of Ethics (1994 - As Amended).

Signature: ________________________________________________

Date: _______________________________________________

FEE: Each application must be accompanied by a registration fee of $100.00 which is non-refundable.

Method of Payment

Cash __________ Cheque ___________ Money Order ___________ VISA ____________

Visa Card Number: ________________________ Expiry Date (mo/yr): _______________

Signature: _____________________________________ Date: ___________________

TO BE COMPLETED BY BOARD OF EXAMINERS OFFICE:

Application Fee __________
Membership Fee ___________
Date Membership Granted ___________