Maturity Matters

Certified Professional Consultant on Aging (CPCA)®

Disclosure Questionnaire and Renewal Order Form

First Name *

Last Name *

If you wish to update your email please contact Jennifer@AgefriendlyBusiness.com Updating your email in this field will confuse the system and will create additional incorrect profiles.

Email *

Who referred you to us?

If other, please tell us who.

Have you or your business ever been sanctioned, reprimanded or convicted (criminal or civil actions) due to inappropriate and/or unethical business conduct? *

YesNo

Have you or your business ever been represented negatively in the media with reference to poor or unethical customer service? *

YesNo

Have you or your business ever received a negative assessment from the Better Business Bureau in response to a customer complaint? *

YesNo

Do you offer a physically safe environment for age 50+ customers? *

YesNo

Are you and your business committed to providing respectful and ethical service to all customers, especially the age 50+? *

YesNo

I confirm that the responses to this qualification form are accurate to the best of my knowledge. *

YesNo

As a CPCA, I agree to abide by the Certified Professional Consultant on Aging Code of Professional Responsibility and as a CAFB, I agree to abide by the Certified Age-Friendly Business Code of Service.* *

YesNo

Click below for a Copy of the Certified Professional Consultant on Aging (CPCA)® Code of Professional Responsibility:

CPCA Code of Professional Responsibility

Click below for a Copy of the Certified Age-Friendly Business (CAFB)® Code of Service:

CAFB Code of Service

Age-Friendly Business (AFB)® maintains the right to rescind the membership and thus the member’s right to hold themselves out as a CPCA or a CAFB if we learn that the answers provided in this form have not been fully accurate, and/or if circumstances change the responses in a material way.