Application for Registered Social Worker Full Registration

Application for Registered Social Worker Full Registration Licensure Exam Requirement: In addition to completing the Application Package, new applicants will be required to complete a competency based Licensure Examination as part of the requirements for registration. Applicants will be approved to write the exam upon successful submission of the completed Application Package and subsequent review by the College. Valid Email: The College communicates primarily via Email. Please provide an up to date Email address on page 3 and add @bccsw.ca to your safe senders list to ensure you receive our communications. Applicants should read through this entire package before starting to complete it. Applications cannot be considered until the requirements of each part are complete and have been received by the College. Part 1: The application has seven sections: 1(a). Personal Information 1(b). Employment Information 1(c). Educational History (see additional requirements) 1(d). Professional Affiliations 1(e). Professional Conduct Disclosure 1(f). Consent to Disclose 1(g). Application Statement Part 2: Three attachments must be provided: 2(a). Application Fee Payment Form (page 6) 2(b). Two letters of reference on the forms provided sent directly to the College by the referees (pages 7&8). 2(c). Completed Consent to Criminal Record Check form (pages 9 & 10) The signed, original form must be MAILED to the College. This is a requirement of the Criminal Records Review Act. Do not take this form to a police detachment. Part 3: There are five additional items: 3(a). Official transcript of highest social work degree mailed directly to the College by the awarding institution Applicants educated outside Canada and the USA must arrange to have a basic report from the International Credential Evaluation Service sent directly to the BCCSW. Find their information at www.bcit.ca/ices 1

2 Applicants who do not have a social work degree should refer to the College s requirements for individuals without a social work degree here. If you have completed all the requirements of your degree but are awaiting conferral, please request an official Letter of Completion to be mailed directly to the College from the educational institution; degrees are not listed on transcripts until after convocation. Applicants must still arrange for an official transcript to be mailed directly to the College after their degree has been conferred by the awarding institution. 3(b). Criminal record checks (this is a separate requirement from 2(c)): Applicants are required to submit a national or federal criminal record check from their country of residence. The original form with the result of the check must be mailed to the College by the applicant if the issuing agency will not send it directly to the College. o If your country of residence is Canada, this requirement can be fulfilled by visiting your local police detachment. o If your country of residence is the USA, you are required to submit an FBI Identity History Summary Check. Criminal record checks are required from any country in which an applicant was a resident or worked in as an adult. If citizenship or permanent residency in Canada has been granted and the applicant has not resided outside Canada since the date of issue, the College may accept proof of a Permanent Resident Card or Canadian Citizenship or Canadian work permit information in lieu of international criminal record checks. A criminal record does not automatically disqualify an applicant from registration; however, it is necessary to provide details of the incident that gave rise to the criminal record. 3(c). An up-to-date resume with complete work history. Applicants may be required to provide additional information. 3(d). A high quality copy of two (2) pieces of identification. One must be government issued photo identification. Applicants born outside Canada must provide proof of Canadian citizenship, permanent residency or work permit with a copy of both sides of their Canadian immigration status. 3(e). Verification of Registration/Licensure form(s) if required Applicants, who are currently or have been in the past registered with another regulatory body, have to submit a completed Verification of Registration/Licensure form from each regulatory body. There are separate forms for social work regulators and non-social work regulators. Please ensure that you are using the appropriate form.

3 Application for Registered Social Worker Full Registration Section 1 Personal Information Legal Last Name: Legal First Name: Date of Birth: Gender: Male Female (MM/DD/ YYYY) Middle Name: Common First Name: Other Names Used or Have Used: (e.g. maiden name, birth name, or previous married name) Last Name: First: Middle: Last Name: First: Middle: Mailing Address: City: Province: Country: Phone #: ( ) Personal Email Address: Postal Code: Section 2 Employment Information If you are employed as a social worker please fill out this section. If you are not yet employed you have to provide this information prior to beginning work. If you practice social work in more than one place, whether part-time, full-time or in private practice, please include an additional piece of paper with all the details listed below for each location of employment. Name of Employer: Worksite: Business Address: City: Province: Country: Postal Code: Business Phone: ( ) Local: Fax: ( ) Work email address:

4 Section 3 Educational History List your highest social work degree. Degree: Year Obtained: Institution: Applicants are required to arrange to have an official transcript of their highest social work degree or credential mailed directly to the BCCSW from the awarding institution. Applicants who do not have a social work degree, please contact the College before proceeding. Section 4 Professional Affiliations Regulatory Body: Regulatory Body: Registration Number: Registration Number: If you are currently or ever have been registered with any other regulatory body in any profession, please complete the appropriate Verification of Registration' form which can be found on our website. Section 5 Professional Conduct Disclosure a. Have you ever been the subject of a finding of professional misconduct or incompetence? b. Are you currently the subject of a proceeding in relation to professional misconduct, or incompetence? YES YES NO NO If you have answered yes to either of the questions above, please attach a separate sheet of paper with details of the situation and findings. Section 6 Consent to Disclose The College offers Registrants the choice to have their business address and telephone number listed on the public registry. If you would like your business address and telephone number published please provide consent and details below. If my application is approved, I consent to the publication of my business address and telephone number to my profile on the College online registry YES NO Business Address: Business Phone: ( )

5 Section 7 Application Statement Canada, Province of British Columbia, in the matter of an application for registration with the British Columbia College of Social Workers I, of (Name) do solemnly declare that: (City) I have not been convicted in Canada or elsewhere of any offence that, if committed by a person registered under the Social Workers Act, would constitute unprofessional conduct or conduct unbecoming a person registered under these bylaws except as follows: My past conduct does not demonstrate any pattern of incompetence or untrustworthiness which would make registration contrary to the public interest. I am a person of good character. My entitlement to practise social work has not been limited, restricted or subject to conditions in any jurisdiction at any time except as follows: At the present time, no investigation, review or proceeding is taking place in any jurisdiction which could result in the suspension or cancellation of my authorization to practise social work in that jurisdiction except as follows: I have read the Social Workers Act of British Columbia, the Bylaws of the British Columbia College of Social Workers made pursuant to that Act. I will practise at all times in compliance with the Social Workers Act of British Columbia, and the bylaws of the British Columbia College of Social Workers made pursuant to that Act. And I make this solemn declaration, conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath. Applicant s Signature: Date: The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the registration process under the Social Workers Act. The collection, use and disclosure of personal information are subject to the provisions of the Freedom of Information and Protections of Privacy Act. If you have any questions about the collection, use or disclosure of this information, please contact the Registrar of the BC College of Social Workers at 604 737 4916.

6 Application Fee Payment Form Amount: $120.00 Payment: Mastercard Visa Cheque Enclosed # Card Number: Expiry Date: M M Y Y CVD/CVV: (three digit number on the back of credit card) Name Printed on Card: Authorized Signature: Please complete and submit with your application Credit Card Holder Contact Information Last Name: First Name: Mailing Address: City: Province: Country: Postal Code: Phone #: Email Address: Fee Information A non refundable fee of $120.00 is required to process the application Fees are payable by Visa, MasterCard, money order or cheque Cheques are payable to the BC College of Social Workers There is a $25 charge for any cheque returned insufficient funds If your application is approved, you will be mailed and approval letter and invoice for registration fees. Initial registration fees are pro rated based on the month of approval.

7 Reference Letter This reference letter must be completed by a professional who has known the applicant for more than one year and is not related to the applicant. The reference letter must be sent to the College directly by the referee. This is a reference for Name of Applicant 1. A. How long have you known the applicant? Year(s) B. In what capacity? 2. How would you describe the applicant s character? 3. Describe the professional attributes of the applicant: 4. Please identify any concern you may have about recommending this applicant for registration: 5. Additional Comments: Referee s Information (Please Print Clearly): Name: Employer: Professional Designation, Degree, Credential: Position Title: Mailing Address: City: Preferred Telephone Number Signature: Province: Postal Code: Date: The personal information requested on this form is collected under the authority of the Social Workers Act for the purpose of administering the registration process. The collection, use and disclosure of personal information are subject to the provisions of the Freedom of Information and Protections of Privacy Act. Disclosure is limited to confirmation of receipt of this letter of reference. If you have any questions about the collection, use or disclosure of this information, please contact the Registrar of the BC College of Social Workers at 604 737 4916.

8 Reference Letter This reference letter must be completed by a professional who has known the applicant for more than one year and is not related to the applicant. The reference letter must be sent to the College directly by the referee. This is a reference for Name of Applicant 1. A. How long have you known the applicant? Year(s) B. In what capacity? 2. How would you describe the applicant s character? 3. Describe the professional attributes of the applicant: 4. Please identify any concern you may have about recommending this applicant for registration: 5. Additional Comments: Referee s Information (Please Print Clearly): Name: Employer: Professional Designation, Degree, Credential: Position Title: Mailing Address: City: Preferred Telephone Number Signature: Province: Postal Code: Date: The personal information requested on this form is collected under the authority of the Social Workers Act for the purpose of administering the registration process. The collection, use and disclosure of personal information are subject to the provisions of the Freedom of Information and Protections of Privacy Act. Disclosure is limited to confirmation of receipt of this letter of reference. If you have any questions about the collection, use or disclosure of this information, please contact the Registrar of the BC College of Social Workers at 604 737 4916.

IMPORTANT: Please read information and instructions on Page 2. PART 1 APPLICANT/REGISTRANT INFORMATION Criminal Records Review Program Consent to a CRIMINAL RECORD CHECK Schedule B Last Name: Full First: Full Middle: Birth Date: Gender: Male Female Birth Place: (yyyy/mm/dd) (City, Province/State, Country) OTHER NAMES USED OR HAVE USED: (e.g., maiden name, birth name, or previous married name) Surname: First: Middle: Surname: First: Middle: Surname: First: Middle: Mailing Address: City: Province: Country: Postal Code: Contact Phone : ( ) BC Driver Licence # : PART 2 ORGANIZATION INFORMATION Organization Name: BRITISH COLUMBIA COLLEGE OF SOCIAL WORKERS Governing Body ID Number (provided by the Criminal Records Review Office): 004 CONSENT FOR RELEASE OF INFORMATION AND ACKNOWLEDGEMENTS: p I have read and understand the Consent for Release of Information and Acknowledgements on Page 2. I hereby p consent to these terms as indicated by my signature below. I hereby authorize my organization as indicated in Part 2 - Organization Information to conduct criminal record checks on an ongoing basis, every five years. I understand that I may contact my organization to withdraw this consent for future criminal record checks. PSSG08-000 01/2008 Applicant Signature Parent or Guardian Signature for Date Signed Applicant Under 19 Years of Age Ministry of Public Safety and Solicitor General Policing and Community Safety Branch Security Programs Criminal Records Review Program Mail Original Form to: BCCSW 1430 1200 West 73 Avenue Vancouver, BC V6P 6G5 Page 1 of 2

Consent to a Criminal Record Check (Schedule B) INFORMATION and INSTRUCTIONS Page 1 is set up with 'form fields' so you may complete it at your computer then print the number of copies required. You may also complete the form by hand, but please print clearly using dark ink. Processing delays will result if form is submitted incomplete, incorrect or if information cannot be read clearly. For information contact the British Columbia College of Social Workers at (604)737 4916. Schedule B: use if the individual is a) an applicant for membership to a governing body or b) is applying for or has certification or a letter of permission under the Independent School Act or c) is a registered student with an education institution with a practicum component involving work with children which leads to certification by a governing body. See website www.pssg.gov.bc.ca/criminal records review/act/who.htm for a complete list of Governing Bodies covered under the Criminal Records Review Act. The governing body, office of independent schools or the education institution retains the consent form. CHECKLIST for Applicant/Registrant I have completed all the applicable sections clearly and legibly. I have read and understand the Consent for Release of Information and Acknowledgements and information regarding the Freedom of Information and Privacy Act (FOIPPA) (outlined below). I have signed and dated the Consent for Criminal Record Check form. I understand the British Columbia College of Social Workers will retain proof of the original form and will submit information from this form for the purposes of the Criminal Records Review Act. CONSENT FOR RELEASE OF INFORMATION AND ACKNOWLEDGEMENTS PURSUANT TO THE BC CRIMINAL RECORDS REVIEW ACT I hereby consent to a check for records of criminal convictions to determine whether I have a conviction or outstanding charge for any relevant offences under the Criminal Records Review Act; I hereby authorize the release to the Deputy Registrar any documents in the custody of the police, the court and crown counsel relating to an outstanding charge or conviction of any relevant offence as defined under the Criminal Records Review Act. Where the results of this check indicate that a criminal record or outstanding charge for a relevant offence may exist, I agree to provide my fingerprints to verify any such criminal record. The Deputy Registrar will notify me and my organization that I have an outstanding charge or conviction for any relevant offence(s) and the matter has been referred to the Deputy Registrar; The Deputy Registrar will determine whether or not I present a risk to physical or sexual abuse to children; The Deputy Registrar's determination will be disclosed to my organization and it will include consideration of any relevant offence for which I have received a pardon; If I am charged with or convicted of a relevant offence at any time subsequent to the criminal record check authorized herein, I further agree to report the charge or conviction to my organization and provide my organization, in a timely manner, with a new signed Consent to a Criminal Record Check form. FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT (FOIPPA): The information requested on this form is collected under the authority of the Criminal Records Review Act and in the case of child care facilities, the Community Care Facility Act, and the regulations which govern both these acts. The information provided will be used to fulfill the requirements of the Criminal Records Review Act for the release of criminal records information and is in compliance with the FOIPPA. Page 2 of 2