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Application for Designation as a Certified Chemical Technologist

*Mandatory fields

Note CSCT membership is required. To become a member visit www.cheminst.ca/membership

CSCT Member #

Salutation

First Name*

Last Name*

Company Name

Address*

Address (Con't)

City*

Country*

Province/State*

Postal Code/ZIP*

Phone*

ext.

Fax

E-mail*

Professional Experience (most recent first)

Please indicate your professional experience over the past five years, or since graduation.

Employer name*

Address*

Address (Con't)

City*

Country*

Province/State*

Postal Code/ZIP*

Phone*

ext.

Name of Supervisor*

Employment Dates

Position held*

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Post Secondary Education (most recent first)

*Mandatory fields

Institution name*
Address*
Address (Con't)
City*
Country*
Province/State*
Postal Code/ZIP*
Program name*
Year of graduation*
Diploma received*

add another institution

Professional Development Courses (most recent first)

Course name
Year of graduation

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Attachments

Please attach any relevant:

Letter(s) from employers
Transcripts
Comparative education reports
Resume

Attachment

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