2025 Probationary Assessment Invoice - College of Physicians & Surgeons of Alberta

PA supervisor information

Supervisor name(Required)

First Last

CPSA registration #(Required)

Payee information (must match what you selected on your agreement)

Payee info(Required)

Self

Professional Corporation

Name of Professional Corporation(Required)

Payee address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

GST # (if applicable)

PRA candidate information

Candidate name

First Last

CPSA registration #(Required)

Invoice amounts

Invoice type(Required)

Interim

Final Invoice

Start date

End date

Total hours

Please enter a number from 0 to 15.

Invoice total amount ($)

Note: Hours listed in this invoice will be payable $200.00 per hour for a maximum of 15 hours for the entire assessment, regardless of the number of supervisors.

Mileage is only reimbursed if visits during assessment takes place outside of Supervisor’s practice location city. If you would like to invoice for mileage, please fill out the fields below:

Invoice type

Interim

Final Invoice

Mileage (in km)

Please enter a number greater than or equal to 0.

Mileage (km) x $0.70

Signature

Email(Required)

This is the email address we will send your confirmation email to.

Enter Email Confirm Email

Date