Physician Extender Application Form - College of Physicians & Surgeons of Alberta

Before starting this form, make sure you have the following documents:

Completed and witnessed Registration Understanding Acknowledgment
Copy of your LMCC certification (wallet card or wall certificate)

Important
You must complete and submit this form at least 30 days before your expected start date. Please see information on our website under Fees and Start Date before selecting a registration date.
Date Physician Extender registration is required (should be typed in the format mm/dd/yyyy, as in 03/15/2023):*
MM slash DD slash YYYY

We will make every effort to complete your registration by this date Note: We cannot issue a backdated practice permit.
Applicant information
Name of applicant:*
Given name(s) Last name
Email:*
Enter Email Confirm Email
Gender:

Female

Male
CPSA registration #:*
Licentiate of the Medical Council of Canada (LMCC) #:
(LMCC number ‐ not your candidate code)
Year LMCC obtained:
Was any of your postgraduate training taken outside of Alberta?*

Yes

No
Date of training outside of Alberta (mm-yyyy to mm-yyyy):*
Name of program:*
Current contact information
(for internal CPSA use only)
Address:*
Street address/PO box City State / Province / Region Postal/Zip code Country
Phone number:*
Pager:
Additional information required
Completed Program Director Support Form*
Accepted file types: jpg, jpeg, pdf, png, tiff, Max. file size: 5 MB.
Completed and witnessed Registration Understanding and Acknowledgment:*
Accepted file types: jpg, jpeg, pdf, png, tiff, Max. file size: 5 MB.
Copy of your LMCC certification (wallet card or wall certificate):*
Accepted file types: jpg, jpeg, pdf, png, tiff, Max. file size: 5 MB.
Signature
Checking this box will act as your signature:*
I confirm I am the applicant and that information in this form is accurate.
Date (should be typed in the format mm/dd/yyyy, as in 03/15/2023):*
MM slash DD slash YYYY
After clicking "Submit", you will be redirected to CPSA's Secure Payment Processing Portal to complete your payment. We require payment to begin processing your request.

After completing payment, we will email you a receipt. That receipt is confirmation that your information was received and your request will be processed. Note: We cannot guarantee a practice permit will be issued.
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Admin fields
For CPSA use only
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Requested Form*
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Quantity*
Please enter a number from 1 to 1.
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Are you a student?*

Yes

No
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Quest Library*
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Document Type*
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Document Name*
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Issuer*
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Recipient*
Phone
This field is for validation purposes and should be left unchanged.

Before starting this form, make sure you have the following documents:

Important

Applicant information

Current contact information

Additional information required

Signature

Admin fields

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