Application form for Continuing Education Programs
Please complete all of the information in the form below.
Name:
First / Middle / Last
Work*
Address:
Residential*
Address:
Number and Street Name
Number and Street Name
City and Province
City and Province
Postal Code
Postal Code
Phone:
Phone:
SCP# D
Email:
Gender:  Male  Female
Date of birth:
Do you have a University NSID (A unique code 3 letter, 3 number)?  No

Yes. What is your NSID?
If you do not have an NSID, we will request that the IT Department generate one for you. It is necessary for you to complete all
of the above information as it is required to create an NSID (3 letters, 3 numbers) and to gain access CPDP online courses.
You must select at least one of the following courses:
 I would like to register for the Prescriptive Authority – Level 1 Basics Online Course - $131.25
 I would like to register for the Prescriptive Authority – Minor Ailments Online Course - $210.00
 I would like to register for the Prescriptive Authority – Minor Ailments Online Course – Part II*- $105.00
 I would like to register for the Prescriptive Authority -- ECP Online Course $157.50
 I would like to register for the Privacy Officer Recertification/Certification Training -- Online Course $183.75
To pay by credit card:  VISA  MasterCard
Name (that appears on the card): ________________________________________
Card Number: ________________________________ Exp: _________________
Signature: ___________________________________
 Pay by cheque (please note, if you are sending a cheque, your application will not be processed until payment is received.)
 Please fax the completed form to the CPDP Office at 306-966-2355
*Please note that Part II of Minor Ailments can only be completed once the first sets of Minor Ailments have been completed
(Acne, Insect Bites and Cold Sores).
Due to the influx and demand of many of our programs, please expect a minimum of 7 working days for our office to process your
NSID application, Level 1 Basics, Minor Ailments and ECP registration forms. Please anticipate a 10 day turnaround time for receipts
and CEU completions. You will be contacted via email once these have been processed. Thank you for your patience.