Thank you, One Last Step before your registration is complete

Please complete the following Disclosure Questionnaire:

Certified Professional Consultant on Aging (CPCA)®

Disclosure Questionnaire and Order Form

First Name *

Last Name *

Email *

Name as you would like it to appear on your certificate *

Has a principal in your company presently or ever been sanctioned, reprimanded or convicted (criminal or civil actions) due to inappropriate and/or unethical business conduct? *

Yes No

Has your company been represented negatively in the media with reference to poor or unethical customer service? *

Yes No

Has your company ever received a negative assessment from the Better Business Bureau in response to a customer complaint? *

Yes No

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

Yes No

Is your company committed to providing respectful and ethical service to all customers, especially the age 50+? *

Yes No

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

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. *

Age-Friendly Business (AFB)® maintains the right to rescind the membership and thus the member’s right to hold themselves out as 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.

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