Supervisor Membership Renewal/Application Supervisor Membership Application/Renewal (1) We welcome you to join QICPE. The membership fee is $30 per year ($31 if paying by credit card.) Member Title*Please selectMsMrMrsMissRevFatherSisterOtherFirst Name* Surname* Address Line 1 Address Line 2 Address- Suburb/Town* State*QueenslandNew South WalesNorthern TerritoryVictoriaSouth AustraliaTasmaniaWestern AustraliaAustralian Capital TerritoryOtherPostcode*Please enter a number from 0000 to 9999.Mobile Telephone* Email* CPE Units conducted and completed since the last AGM - Include location, number of participants finishing, mode (eg F-T, P-T)*For Lapsed Supervisors: Please provide a name and phone number of the current QICPE R and C Chair to nominate you for supervisory membership. Mandtory Declaration* As a CPE Supervisor member of QICPE Inc, I have read and will abide by the QICPE Inc Code of Ethics and Professional Practice for Supervisory members (QICPE Standard 9.5) as found at https://qicpe.com/curriculum/ Declaration of Professional Conduct* I declare that no formal complaints have been received against me in the previous 12 months. I declare that a formal complaint is currently being investigated. I declare that a formal complaint has been investigated and I provide a summary of the outcome. Declaration of Professional Development* I declare that I have completed the required hours of professional development for my accreditation status, that these records are kept in a logbook and that I will send this logbook to the R and C Chair. I have been unable to complete the required hours of professional development in the past 12 months. I have not completed the required hours of Professional Development for the following reason/s:One Year Membership Price: $50 if paid by Direct Deposit or cheque. $51 if paid by credit card online.Payment Method*Please SelectDirect Deposit to QICPE Inc; Account # 186321 BSB 034-072- please use your surname as the desciptionCredit Card securely via Stripe - $51Cheque payable to QICPE Inc, post to PO Box 37, Everton Park QLD 4035Please advise our Treasurer, Trish, of any payments via email: firstname.lastname@example.orgPhoneThis field is for validation purposes and should be left unchanged.