License Application Fellow of CSI (FCSI®)

a. Please indicate the designation you hold and are using towards achieving the FCSI®.

b. Two (2) Additional CSI Courses

Courses must be from a different stream than that leading to the Designation specified in item a). For additional information, please visit the Learning Path section on the FCSI® website at www.fcsi.ca.

I confirm that:

EXPERIENCE VERIFICATION CONTACT INFORMATION

Please provide contact information for the person (or persons) who will be able to verify your work experience declaration. On this application, you are required to provide details on your length of employment within each position you have held, which will allow CSI to affirm that the 7 years out of the last 10 have been fulfilled. However, you are given the option of providing one or more verifiers. For example, if your current supervisor is able to confirm all of your past experience, then you will require only one verifier. If, however, your current supervisor is not able to verify all past experience, then you will need to include your current supervisor (for current position) and one or several past supervisors to cover the other positions you have provided for the fulfillment of the required experience.

Provision of this contact information is your acknowledgement that CSI may retain this information on your file and contact the individual for this purpose only.

ENDORSER CONTACT INFORMATION

Please provide contact information for your endorsement declaration. Provision of this contact information is your acknowledgement that CSI may retain this information on your file and contact the individual noted for this purpose only.

Have you ever been accused of professional misconduct, disciplined or reprimanded by, or had a licence suspended or revoked by, an employer, professional association or administrative or regulatory authority (i.e. securities commission, law society, real estate association, Have you ever been accused of professional misconduct, disciplined or reprimanded by, or had a licence suspended or revoked by, an employer, professional association or administrative or regulatory authority (i.e. securities commission, law society, real estate association, CIRO, Insurance Regulator, FINRA, etc.)?, Insurance Regulator, FINRA, etc.)?

Are you currently bankrupt or have you at any time in the past 5 years been adjudged bankrupt?

Have you ever been convicted of a criminal offence* in any jurisdiction for which a record suspension or a pardon has not been granted?

Have you ever been convicted of an offense under any financial services or consumer protection legislation in any jurisdiction (i.e., laws regulating the sale of securities, insurance, real estate, mortgages, etc.)?

If you have answered “Yes” to any of the questions above, please attach all relevant paperwork, including details of any punishment or disciplinary action taken. Any information you provide will be collected, stored and used in accordance with applicable law and our privacy policy and will be shared with the Designation Ethics Committee to determine your suitability for the designation.

* “Criminal offence” excludes an offence (i) under a provincial regulatory statute, such as the Highway Traffic Act, unless the provincial statute is specifically listed above and unless the provincial conviction involved an offence of dishonesty or theft, such as perjury or subornation of perjury, false statement, fraud, embezzlement, or false pretense, or any other offense the commission of which involves some element of deceit or untruthfulness, and (ii) an offence punishable by summary conviction only that is not an offence of dishonesty or theft.