Apply to be a CESA / ECSA Verified CPD Service / Training Provider * = required field Organisation Details Company Name * Known As / Trading As Phone NumberFormat e.g.: +27 (0)11 463 2022 +(0) Cell Number *Format e.g.: +27 (0)82 XXX YYYY +(0) Website Email Address * VAT No Physical Address Physical Address Line 1 Physical Address Line 2 City * Code * Province * Please select Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga North West Northern Cape Western Cape International Country * Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (see Timor-Leste) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe Person who is applying for verification on behalf of the organisation Title * Mr Ms Mrs Dr Prof Initials First Name (Known As) * Surname * Position Held ID / Passport Number Phone Number +(0) Cell Number * +(0) Email Address * Person who is acting as the administrator on behalf of the organisation Same as above Title Mr Ms Mrs Dr Prof Initials First Name (Known As) * Surname * Position Held ID / Passport Number Phone Number +(0) Cell Number * +(0) Email Address * Upload Documents The CPD Service/Training Provider is required to upload evidence of the following, related to your company, the administration and offering of CPD Activities. Company Profile * Valid certified company registration certificate * Valid tax clearance certificate (good standing with SARS or equivalent) * BBBEE Certificate or Affidavit FICA compliant / Proof of office/residential address *Any valid documents reflecting your company's name and physical office address. i.e. Recent active lease or rental agreement, Municipal rates and taxes invoice Copy of ID book or driver's license of applicant * Proof of payment Evidence of a comprehensive Quality Management System (QMS), which includes the following elements: • A broad outline of the programme for the forthcoming year * • Quality assurance / strategies employed for the CPD Activities * • Method for recording attendance * • Intended mechanism for monitoring attendance (per hour or per session) for the duration of the activity * • Proposed attendance register (with evidence of copy) * • Attendance certificate that will be provided on completion of the activity * • Method to be used for obtaining feedback or evaluation of the CPD event * • Database containing information of CPD Activities * • Process and reimbursement clause for the reimbursement for registration fees, accommodation and other costs incurred during the validation of the CPD Activity * I confirm that I am an authorised representative of the above organisation, and authorised to hereby apply on behalf of the organisation to be recognised as a ECSA CPD Verified Service Provider in terms of the Rules: Continuing Professional Development and Renewal of Registration (Board notice 86 of 2017) and Section 10 of the Standard for Continuing Professional Development (ECPD-01-STA). I confirm that the information and documentation supplied is, to the best of my knowledge, accurate and complete.