Continuing Education/Industry Contribution Exception Request Form

Student ID *

Identity Verification Birthdate *

Name *

First

Last

Gender *

Language preference for communication *

Preferred Email Address *

Alternate Email Address

Phone number to reach you *

Personal Phone *

Business Phone *

Address *

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Business Branch Transit Number (if applicable)

Employee Number

Employer

Direct Manager

Business Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please select the exception you wish to request: *

Request the exception due to: *

Year and Length of Exception Requested *

Please provide details explaining the need for the exception.

Documents to support the need for the exception *

Click or drag files to this area to upload. You can upload up to 20 files.

Declaration *

I, the undersigned state that the information contained in this request is accurate and permit CSI to verify any information provided in this request.

Signature *

Clear Signature