License Application Fellow of CSI (FCSI®)

PERSONAL INFORMATION

Student ID *

Identity Verification Birthdate *

Please indicate your name (including any initials used) exactly as it appears on your government-issued photo ID. *

First

Middle

Last

Gender *

Female
Male
Non-Binary

Language preference for communication *

English
French

Preferred Email Address *

Alternate Email Address

Phone number to reach you *

Personal
Business
Both

Address *

Home Address
Business Address
Both

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Business Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

To which address would you like us to send your Certificate *

Business Address
Home Address

Which address would you like listed in our FCSI® directory? *

Business Address
Home Address
I do not wish to have my address listed

FCSI® EDUCATIONAL REQUIREMENTS

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

Designation *

* NOTE: External Designations are subject to CSI’s External Designation Recognition policy and fee. See details at www.fcsi.ca.

Year granted *

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.

CSI Course (1) *

Year Passed *

CSI Course (2) *

Year Passed *

c. Financial Services Industry: Business Drivers and Challenges course (FSDC)

Year Passed *

FCSI® DECLARATION AND SIGNATURE OF APPLICANT

Declare *

I declare that I have completed this application as completely as I am able and I hereby apply for the Fellow of CSI (FCSI®).

I confirm that:

WORK EXPERIENCE REQUIREMENTS *

I declare that I have worked in the financial services industry for seven (7) of the last ten (10) years. I understand that this declaration will be verified by CSI and that CSI will contact the person I have identified (for verification purposes only).

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.

From (YYYY-MM)

To (YYYY-MM)

Organization Name

Name

First

Last

Email Address

Phone Number

Language preference for communication

English
French

From (YYYY-MM)

To (YYYY-MM)

Organization Name

Name

First

Last

Email Address

Phone Number

Language preference for communication

English
French

From (YYYY-MM)

To (YYYY-MM)

Organization Name

Name

First

Last

Email Address

Phone Number

Language preference for communication

English
French

ENDORSEMENT REQUIREMENTS *

I declare that my supervisor will endorse me for the FCSI® credential. I understand that this declaration will be verified by CSI and that CSI will contact the person I have identified (for verification purposes only).
I declare that an active Fellow of CSI will endorse me for the FCSI® credential. I understand that this declaration will be verified by CSI and that CSI will contact the person I have identified (for verification purposes 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.

Name *

First

Last

Organization Name *

Email *

Phone *

FIT AND PROPER REQUIREMENT

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.

INDUSTRY CONTRIBUTION REQUIREMENTS *

I understand, and agree to comply with the FCSI® Industry Contribution Requirements to complete a minimum of 12 hours per calendar year as set out in the FCSI® Industry Contribution Assessment Tool.

You are not required to submit your documentation on an annual basis, however from time to time some members may be subject to random audits.

TRADEMARK LICENSE AGREEMENT *

By signing below I confirm that I have read and consent to the terms and conditions of this Information Release Consent.

Signature *

Clear Signature