Provision of Professional Services
Application: Approval of Practice Setting (Accredited Practice Setting)
Practice Setting Information
Name of Practice Setting
*
Practice Setting Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Practice Setting Phone Number
*
Format: (000) 000-0000.
Practice Setting Email
*
example@example.com
Practice Setting Website Address
*
Organization
Name of the Organization Operating the Practice Setting
Name of Organization if different than practice setting name
Designated Contact
Designated Contact's Name
*
First Name
Last Name
Designated Contact's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Designated Contact's Email
*
example@example.com
Accreditation
Accrediting Body
*
Accreditation Canada
Commission for the Accreditation o Rehabilitation Facilities (CARF)
File Upload: Accreditation Status
*
Browse Files
Proof of current accreditation status. Only PDF documents are accepted. One document per file upload.
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of
Acknowledgements
As the Designated Contact, I certify and declare that:
*
The information provided on this application is true.
Submission
Submission Date
*
-
Year
-
Month
Day
Date Picker Icon
Designated Contact's Signature
*
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