Supervision Plan for Applicants and Provisional Members

Employment Verification
For Office Use Only: Job # and Workplace
This form must be completed for each employment position assumed during the provisional practice period.

Please complete and submit the applicant/provisional member information. The form will then be automatically forwarded to your employer for employer information and signature.
Applicant/Provisional Member's Name*

First NameLast Name
Applicant/Provisional Member's Email*
Job Title:

Once provisinally licensed, if your job title will not be Registered Psychologist or Registered Doctoral Psychologist OR if your job title does not indicate that you will conducting psychological activities, please attach an official employment role and function. The employment role and function must clearly indicate that the provisional member will be engaged in the provision of psychological services.
Official Employment Job Role and Function

Cancelof
Provisional Applicants - Job Title once Provisionally Registered
Provisional Members - Job Title with Employer
Employer:
Employer's Name

First NameLast Name
Employer's Email
Job Title
Name of Work Place
Is this a private practice?

YesNo
If yes, how many psychologists are employed?
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Employer Signature

Clear
Date

MonthDayYear
Saskatchewan College of Psychologists

1026 Winnipeg Street, Regina, SK S4R 8P8
Telephone: 306-352-1699/Fax: 306-352-1697
Email: skcp@sasktel.net
Website: www.skcp.ca
Should be Empty:

Employment Verification