Secure Registration Form

This form to be used only when:

1. You have now successfully completed the 4 EPC Designation modules available on the Pro-Seminars online self-study site and you want to write the Proctored Elder Planning Counselor Designation Qualification Examination. This exam consists of 125 multiple choice questions. You need to achieve a 70% pass mark to successfully achieve your EPC Designation. The fee for the EPC Qualification examination is $175 plus HST / GST for your Province of residence.

2. You need to schedule an EPC Qualification examination rewrite. The fee for this is $150 plus HST / GST for your Province of residence.

Please enter your name as you want it to appear on any EPC Certificates

First Name Last Name

Canadian Insurance Participant Registry (CIPR#)

(Not everyone has a CIPR # number from the Canadian Insurance Participant Registry)

Company

Address City

Province Postal Code

Business Phone Home/Cell Phone

Fax Your Email Address

Degree(s) Held

Designations or Certifications

License(s):

LEGAL AND DISCLOSURE REQUIREMENTS

Have you ever been convicted of a Criminal Offence for which you have not been granted a pardon?

NO YES

Have you ever been disciplined or had any restrictions placed on any professional license, permit, certificate, registration, or membership denied, suspended, revoked, or restricted, or have you had an application withdrawn for cause by any regulatory body, or any professional organization or association of which you are a member?

NO YES

Have you ever been censured, fined, or reprimanded by any regulatory body, professional organization, or association of which you are a member?

NO YES

* A positive answer to either of the above does not mean that you may not apply but be prepared for a delay in your registration while we investigate your circumstances.

I will abide by the CIEPS Member Code of Professional Conduct.

NO YES

Questions? Type anything you need help with in the box below.

Please let us know if you are registering for an EPC Live class or the EPC Qualification examination.

I am registering for

Referred by


You have 3 options to pay: 1. By Credit Card

Credit card information Card Number Expiry Date 20 CVV2 # (3 Digit Code on the back of your Credit Card) Please note: All charges are completed manually. 2. By Interact Email Transfer to - payments@cieps.com You do not require a password for this option. 3. By cheque payable to - CIEPS Mail cheque to: Canadian Initiative for Elder Planning Studies 4438 Ontario Street, Suite 203 Beamsville, ON L3J 0A4 Type 1234 in the box to the right then click Submit Form:

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Pro-Seminars is an approved and accredited education provider specializing in 2-day 15 CE credit seminars and online CE courses.


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