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Personal Information

Name: *

Company/Firm: *

Address: *

Work Phone: *

Work Fax:

E-Mail: *


Lawyers

Professional Association Membership:

Year Called to Bar:

Member of Law Society of Manitoba?  Yes No

In good standing?  Yes No

Practice Status:

Professional Liability Insurance?  Yes No

Insurance Carrier:

Amount of Coverage:

Total Years of Practice:

Years of Practice in Manitoba:

Mental Health Professionals

Professional Association Membership:

Professional Degrees/Training Certification:

Registration/License Number:

Year registered/licensed:

Professional Liability Insurance?  Yes No

Insurance Carrier:

Amount of Coverage:

Total Years of Practice:

Years of Practice in Manitoba:

Years of Practice in another province or country (specify):


Financial Specialists

Professional Association Membership: (CFP - Certified Financial Planner, etc)

Designation(s):

Date Received:

Fee Only Planning Professional Liability Insurance?

Insurance Carrier:

Amount of Coverage:

Years of Practice:

Collaborative Practice Training

Collaborative Practice Training/Education:  Yes No

Conflict Resolution Training:  Yes No
(including Mediation and Negotiation training)

List Collaborative Practice courses, seminars, conferences, etc. in which you have participated; list any certificates, diplomas or degrees you have received:

Include a personal biography (approximately 150 words) highlighting your areas of expertise; for inclusion on our website. (See website for examples)

Provide information regarding a link to a website (i.e. personal or firm website):

Permission to make linkage:  Yes No



Fees:

$225 per year (Member)

Fees may be adjusted to reflect partial year membership. Membership year is October 1st to September 30th. Membership dues received after September 30 are considered late and are subject to an additional $25 charge.

Cheques are payable to: Collaborative Practice Manitoba Inc.

CPM Membership Committee will review and provide candidate the determination of membership status (Full, Associate, Other). A CPM representative will contact candidate to provide appropriate remitting instructions.