Preliminary Clinical Assessment (PCA) Invoice - College of Physicians & Surgeons of Alberta

PCA assessor information

Assessor 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 weeks

Please enter a number from 0 to 12.

Invoice total amount ($)

Note: The weeks listed in this invoice will be payable at $2000.00 per week for a maximum of 12 weeks for the entire assessment, regardless of the number of assessors.

Signature

Email(Required)

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

Enter Email Confirm Email

Date