Postgraduate trainee referee form - College of Physicians & Surgeons of Alberta

Applicant information

CPSA Registration number(Required)

The applicant's Registration number has been provided to you in the reference request email.

Referee: Relationship to applicant

Please state your relationship(Required)

Describe your role when you knew this applicant(Required)

Duration of working relationship with applicant(Required)

From (mm/yyyy) to (mm/yyyy)

Referee: Assessment of applicant

4. Professional ethics

Please explain "No" answer(Required)

5. Professional conduct

Please explain “Yes” answer(Required)

6. Additional information: Please provide any other comments or information you feel are important to include(Required)

Referee (your) information

Referee phone(Required)

Referee discipline/specialty(Required)

Signature

Thank you for acting as a referee on behalf of the applicant. The content of this form is confidential, for use by CPSA as part of the information submitted in support of the candidate’s application and will not be shared with the applicant or any other parties.

Date(Required)

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Admin Fields

for CPSA use only

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Quest Library(Required)

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Document Type(Required)

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Document Name(Required)

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Recipient(Required)

Applicant information

Referee: Relationship to applicant

Referee: Assessment of applicant

Referee (your) information

Signature

Admin Fields

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