D11 Candidate Professional Declarations Form

CANDIDATE PROFESSIONAL DECLARATIONS 

This form is to be completed and submitted to the Training Committee annually (training@jungiananalysts.org.uk) and again prior to your Final Review. Awarding of AJA Membership is contingent upon the information in this form.

 

NAME:                                                                                            DATE:

 

CLINICAL EXECUTORS

Clinical executor (1)

Name:

Telephone:

Email:

(If not in AJA, please confirm this colleague’s professional training.)

 

Clinical executor (2)

Name:

Telephone:

Email:

(If not in AJA, please confirm this colleague’s professional training.)

 

 

I confirm that I have two clinical executors as listed above.

 

Signed:                                                                                            Date:

 

NEXT OF KIN

Name:

Telephone:

Email:

 

PROFESSIONAL INDEMNITY INSURANCE DECLARATION

 Name of Insurance Company:

Address of Insurance Company:

Name of Policy Holder:

Policy Number:

 

I confirm that I am appropriately insured with the above named insurance company.

 

Signed:                                                                                            Date:

 

 

DECLARATION CONCERNING COMPLAINTS AND/OR CRIMINAL OFFENCES

I confirm that, at present, I am not the subject of any Complaint lodged with UKCP or BPC

I also confirm that in the last 12 months I have not been convicted of a criminal offence nor disciplined, suspended or struck off by any professional regulatory body.

 

Signed:                                                                                            Date:

 

REGISTRATION BODY MEMBERSHIP – UKCP, BPC OR OTHER – DECLARATION

 

I am an individual member of UKCP

Membership No:

Renewal Date:

 

I am an individual member of BPC

Membership No:

Renewal Date:

 

I am an individual member of (name of other organisation)

Membership No:

Renewal Date:

 

I intend to renew my membership(s).

 

Signed:                                                                                            Date:

 

 

SAFEGUARDING DECLARATION

I have successfully completed a safeguarding course.

Name of course:

Date of completion certificate:

Date certificate expires:

 

Signed:                                                                                            Date:

 

Updated  7.11.19

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