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Print Form College of Alberta School Superintendents Regulated/ Provisional Regulated Member Registration Application Form July 1, 2011 - June 30, 2012 Regulated/Provisional Regulated Members meet CASS qualifications and are outside the scope of the Collective Agreement. They include school jurisdiction system educational leaders of the public and separate school jurisdictions in the Province of Alberta and the Northwest Territories, in Charter Schools in Alberta and in school jurisdictions located within the First Nations of Alberta. Name: (Last) (First) Jurisdiction Position Held Email Zone Address City/Town Province Work Phone Cell Postal Code Fax Membership Type Checklist (Please complete) If any boxes are left unchecked, please indicate that you are applying for Provisional Regulated Membership. Your membership will be reviewed and you may be allowed up to 3 years to complete the requirements for Regulated Membership. Contract Outside Collective Agreement 3 Yr. teaching experience AB. B. Ed or equivalent 3 Yr. admin. experience AB. Masters or equivalent Hold System Education Leader Position AB. Teaching Certificate Member in Good Standing I accept the College of Alberta School Superintendents Professional Code of Conduct and Practice Standards as presented on the CASS website at www.cass.ab.ca I meet all the qualifications for Regulated Membership OR Provisional Regulated Membership Signature (Insert digital signature or print form and manually sign) Date FEES: Fees are due no later than October 31st. CASS membership fee is comprised of $985.00 plus GST of $49.25 for a total of $1034.25 (GST Number - 10696 7052 RT) PLEASE NOTE: The jurisdiction will be sent an invoice for membership fees. Do not remit payment until then. I am a current CASS Member since I am a new CASS Member Please print the form using the PRINT button in the upper right hand corner. The form may then be sent via mail, via fax or scanned and sent via email to: Kath Rhyason, Executive Director College of Alberta School Superintendents #1200, 9925-109 Street Edmonton AB T5K 2J8 Fax 1-780-482-5659 email kath.rhyason@cass.ab.ca -------------------------------------------------------------------------------------------------------------------------------------------Office Use Only Membership Register Number Receipt Number Notes