Program Application – ACPAC Program

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Name*

Prefix First Last

Email (Primary)*

Home Phone*

Home Fax

(if applicable)

Cell Phone

Address*

Street Address Address Line 2 City Province Postal Code

How did you hear about the ACPAC program?*

Institution Name

Address

Street Address Address Line 2 City Province Postal Code

Business Phone

Business Phone Extension

Business Fax

Institution from which Professional Degree was issued

Professional Designations

Year of Graduation

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Institution / Workplace

Name

Prefix First Last

Admin Phone

Admin Extension

Admin Email

Admin Address

Street Address Address Line 2 City Province Postal Code

Please indicate which of the following prerequisite courses you have completed:

Clinical Practice Skills for Inflammatory Arthritis (CPSIA) program offered by the Arthritis Society

Date CPSIA program completed

Assessment and Management of Rheumatic Diseases: A skills workshop offered by the ACE Program

Date Assessment and Management of Rheumatic Diseases completed

An equivalent course to the above

Equivalent course name and date completed

None of the above

CPSIA Course

I have registered for an upcoming CPSIA course

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