Society of Certified Senior Advisors
Society of Certified Senior Advisors, providing the premier education and credential for professionals serving seniors
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Renewal Application for Certified Senior Advisor (CSA)®

Complete and submit this Renewal Application with your credit card information:

Your renewal fee is: $195
Offer Code:


Contact Information

First Name: *  
Last Name: *  
M.I.:  
Email: *  
Work Phone: Ext:  
Company:
Mailing Address:
Street:  
City:  
State:  
Zip:  

Benefits Check-up
Are you receiving your CSA publications: the CSA Journal, Senior Spirit & Success w/ Seniors e-newsletters?
  
Do you know how to access your member benefits via your Member Portal account?  Yes   No
Would you like to stop receiving paper renewal statements and get them by email only?  Yes   No
(you can always go back to paper statements at any time)
 
Is there any benefit you wish was offered with your CSA membership?
 
Do you have a suggestion for a webinar topic, client handout or SCSA in general?

Credit Card Information
You should receive a receipt as soon as your renewal is processed. If you don’t receive one within 2 business days, please contact us at 800-653-1785 or society@csa.us. All renewal fees are non-refundable




Account Number:  
Expires:  
Name On Card:  
Billing Zip:  
CVV #:  
 
Do you have referral vouchers to redeem?
Enter the voucher number and dollar amount here:
Voucher:Amount:
Amount:

CSA Disclosure Questionnaire
If you answer "yes" to any of these questions, you must set forth the principal facts relating to each incident in the section provided below. If SCSA requires more information to make a decision regarding your application they will contact you.
In the last 12 months... YES NO
  1. ...have you been accused or convicted of a felony?
  2. ...have you been a defendant or respondent in any criminal action relating to your professional or business conduct, or are you currently named as a party in any such action?
  3. ...have you been a defendant or respondent in a civil action, which includes, but is not limited to, a lawsuit, arbitration, or mediation relating to your professional or business conduct, or are you currently named as a party in any such action?
  4. ...have you had a license, permit, certificate, registration, or membership denied, suspended, revoked, or restricted by any governmental, regulatory, or administrative body, or has any such body censured, fined, restricted or reprimanded you?
  5. ...has any governmental, regulatory, or administrative body named you as a subject of an investigation or complaint?
  6. ...have you been censured, fined, reprimanded, or otherwise disciplined by any professional credentialing organization to which you did or do belong, or has such organization named you as a subject of an investigation or complaint?
Please include a detailed written explanation for any "yes" answers above (SCSA may contact you to clarify your explanation or to provide additional information):  

 

CA Department of Insurance Disclaimer
I am licensed by the California Department of Insurance:   
 
 
By submitting this form, I certify that the above answers are true, and I agree to comply with all rules, requirements, and standards of Society of Certified Senior Advisors® (SCSA) now in effect or issued from time to time, including usage standards for the Certified Senior Advisor (CSA)® designation and all other SCSA proprietary marks. SCSA reserves the right to rescind my CSA designation if it determines that I have violated its rules or standards and refused to abide by compliance directives.
  

 

 

 

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Society of Certified Senior Advisors
1325 South Colorado Blvd., Suite B-300, Denver, CO 80222   |   Phone: 800-653-1785