customer_registration_form_template

Profile

Contact type:

Surname: *

Name: *

Member ID:

Member of the Board of administrators:

Role within board of administrators

Member of the Committee

Personal information

Email (Personal):

Email (work):

Home - Street:

Home - City:

Home - State:

Country:

Home - Postal code:

Phone (personal):

Phone (work): *

Years of Experience in Environmental Sector * :

Professional association(s) of which you're part * :

Type of Professional * :

Highest level of education * :

Field of studies * :

I have liability insurance coverage with my employer

I have private liability insurance coverage

Member Status:

Proof of student status

Active:

Partner's Logo

LinkedIn profile link:

Employer Contact Details

Employer * :

Employer - Administrative region * :

Employer - Street * :

Employer - City * :

Employer - Province * :

Employer - Country * :

Postal code:

Job Title * :

Professional designation * :

AQVE File

Year of CESA® Accreditation * :

Year of CEA® Accreditation * :

Year of JrCESA® Accreditation * :

Year of JrCEA® Accreditation * :

End-year of CESA® juniorate * :

End-year of CEA® juniorate * :

Year of CESA® triennial renewal * :

Year of CEA® triennial renewal * :

CESA® Certificate Number * :

CEA® Certificate Number * :

CESA® title VALID * :

CEA® title VALID * :

TCRC title VALID * :

I wish to relinquish my title as CESA®:

I wish to relinquish my title as CEA®:

I wish to drop-out of my CESA® juniorate program:

Date of last payment received:

Renewal date:

Membership fee due:

Date of last update to the competencies maintenance form:

Enrollment date:

I wish to receive emails from the AQVE

I would like to get involved in a committee

Accreditation committee

I would like to offer training to AQVE members

I would like to become a mentor for a future jrCESA® or jrCEA®

I wish to appear in the accredited members directory

Languages spoken fluently:

Declaration of the approved

Declaration of the approved- F019

I've read the clause under section "1. Utilisation du ou des certificats" du F019_Formulaire_dengagement_agréés and hereby declare I will respect it

I've read the clause under section "2. Conduite de l'agréé" du F019_Formulaire_dengagement_agréés and hereby declare I will respect it

I've read the clause under section "3. Maintien et renouvellement" du F019_Formulaire_dengagement_agréés and hereby declare I will respect it

I've read the clause under section "4. Manquements" du F019_Formulaire_dengagement_agréés and hereby declare I will respect it

TCRC Statement- F013

I've read the clause under section "1. Utilisation du ou des certificats" du CT-F013_Formulaire_dengagement_agréés and hereby declare I will respect it

I've read the clause under section "2. Conduite de l'agréé" du CT-F013_Formulaire_dengagement_agréés and hereby declare I will respect it

I've read the clause under section "3. Maintien et renouvellement" du CT-F013_Formulaire_dengagement_agréés and hereby declare I will respect it

I've read the clause under section "4. Manquements" du CT-F013_Formulaire_dengagement_agréés and hereby declare I will respect it

Maintaining skills - Practice

Practice- 2023

2023 - Number of Hours of Professional Practice: *

2023 - Number of Days of Professional Practice: *

2023 - Number of Verifications:

2023 - Number of Evaluations:

2023 - I have not executed any mandates in 2023 (specify the reason):

Practice- 2024

2024 - Number of Hours of Professional Practice:

2024 - Number of Days of Professional Practice:

2024 - Number of Verifications:

2024 - Number of Evaluations:

2024 - I have not executed any mandates in 2024 (specify the reason):

Practice- 2025

2025 - Number of Hours of Professional Practice:

2025 - Number of Days of Professional Practice:

2025 - Number of Verifications:

2025 - Number of Evaluations:

2025 - I have not executed any mandates in 2025 (specify the reason):

Continuing education

Continuing training - 2023

Number hours of continuing education (as participant): *

Training certificates: *

Hrs spent in meetings of an association: *

Specify in comments: *

Hrs spent visiting facilities as part of a conference: *

Specify in comments: *

Hrs spent participating in committees: *

Specify in comments: *

Hrs spent on article drafting: *

Specify in comments: *

Hrs spent presenting in public as author: *

Material presented (optional): *

Hrs spent preparing training material: *

Specify in comments: *

Hrs spent disseminating training: *

Specify in comments: *

Article(s) published (optional): *

Training material prepared (optional): *

I have not spent any time on continuing education in 2023 (select the reason): *

Continuing training - 2024

2024 - Number hours of continuing education (as participant):

Training certificates:

Hrs spent in meetings of an association:

Specify in comments:

Hrs spent visiting facilities as part of a conference:

Specify in comments:

Hrs spent participating in committees:

Specify in comments:

Hrs spent on article drafting:

Specify in comments:

Hrs spent presenting in public as author:

Material presented (optional, ):

Hrs spent preparing training material:

Specify in comments:

Hrs spent disseminating training:

Specify in comments:

Article(s) published (optional):

Training material prepared (optional):

I have not spent any time on continuing education in 2024 (select the reason):

Continuing training - 2025

Number hours of continuing education (as participant):

Training certificates:

Hrs spent in meetings of an association:

Specify in comments:

Hrs spent visiting facilities as part of a conference:

Specify in comments:

Hrs spent participating in committees:

Specify in comments:

Hrs spent on article drafting:

Specify in comments:

Hrs spent presenting in public as author:

Material presented (optional):

Hrs spent preparing training material:

Specify in comments:

Hrs spent disseminating training:

Specify in comments:

Article(s) published (optional):

Training material prepared (optional):

I have not spent any time on continuing education in 2025 (select the reason):