Title: Mr. Ms. N/A Full Name: Phone: Email: Evaluator # (See registry of evaluators): Evaluator Qualifications

Address: City: Province or Territory: Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code:

Accessible
Intercity
Tour/Charter
School
Urban

Company: Address: City: Province or Territory: Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code: Position: How many years:

If less than 3 years, please proceed to Prior Employer below

Indicate Level of Education: University College High School Certificate Courses Continuing Education Programs Company Training

I have read and consent to the Code of Ethics

Upon approval of the application, I give permission for my name and business contact information to be included in the MCPCC online Certified Professional Instructor National Directory.

PIPEDA Policy Statement:
The Motor Carrier Passenger Council of Canada (MCPCC) is committed to protecting any of your personal information in our possession. We will not disclose any of your personal information other than for its intended use. We will only use any personal information for identified purposes set out in MCPCC’S mandate and we will not disclose or use this information without obtaining consent from you. We will work to ensure that any third parties that we do business with are compliant with Personal Information Protection and Electronic Documents Act (PIPEDA). MCPCC is committed to protecting your electronic and paper based data to prevent unauthorized access, disclosure or misuse.