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Application for Designation as a Certified Chemical Technologist

Please print this form, fill it out and send it to the CSCT address found on the bottom of the form.

Name:  
CSCT Membership No.:  

 

Address:  
 
 
 

 

Tel: (Bus.) (Res.)
Fax:  
E-mail:  

 

Professional experience over the past 5 years, or since graduation (most recent first):

Employer:
Name:
Address:
 
 
 
Briefly describe position(s) held:
 
 
 
 
Name of Supervisor:
Employment Dates: From _______________ to _______________

 

Employer:
Name:
Address:
 
 
 
Briefly describe position(s) held:
 
 
 
 
Name of Supervisor:
Employment Dates: From _______________ to _______________

 

Post Secondary education: (please list most recent first)

Institution:
Name:
Address:
 
 
 
Course name:
 
Diploma Received:
Year of Graduation:

 

Institution:
Name:
Address:
 
 
 
Course name:
 
Diploma Received:
Year of Graduation:

 

Additional professional development courses:

 
 
 
 
 
 

 

Please send this form to:
Career Services Manager
Canadian Society for Chemical Technology
130 Slater St., Suite 550
Ottawa, ON  K1P 6E2