Pre-Authorized Payment (PAP) Enrolment Form - College of Physicians & Surgeons of Alberta

I authorize the College of Physicians & Surgeons of Alberta (payee) to debit my account (as identified by the uploaded void cheque) for:*

Annual CPSA Practice Permit fee 
Annual Professional Corporation fee 
Both of the above fees

Upload void cheque:*

Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.

Accepted file types: pdf, jpeg, jpg, png, tiff, Max. file size: 5 MB.

Is this a joint account?*

Yes

No

I confirm:
I have authorization from all joint holders to use this account for this purpose.

Payor Information

Name*
First Last

Email*
This is the email address we will send a submission confirmation notification to.
Enter Email Confirm Email

CPSA registration #:

CPSA professional corporation #:

Signature

Consent*
I authorize debit to take place in December each year, for the fee(s) applicable for the following calendar year. I further authorize increases to these amounts, as established by CPSA Council.*

Consent*
I understand I can cancel this authorization at any time by notifying CPSA in writing. I also understand I am responsible for providing CPSA with a new void cheque if I change my banking information. (see note #1 below)*

Checking this box will act as your signature:*
I understand the contents of this form and confirm information included is accurate.

Date*
DD dash MM dash YYYY

Important notes

1. If this account is closed, it is your responsibility to notify CPSA immediately of alternative arrangements for payment of the annual fee(s).

2. Only Canadian bank accounts are eligible for CPSA’s PAP plan.

3. PAP plan members must still complete and submit the Renewal Information Form (RIF) and, if applicable, any Professional Corporation Information Forms (PCIF).

4. See the complete Pre-Authorized Payment (PAP) Terms and Conditions.

Name
This field is for validation purposes and should be left unchanged.

Payor Information

Signature

Important notes

CPSA’s 2021 annual report: humanity of health care