Physician Extender (Limited) Form

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

    Only complete this application if you are a psychiatry resident or fellow who is currently enrolled in a psychiatry postgraduate training program in Alberta, AND
    1. 1. Have completed a minimum of two years postgraduate training in psychiatry,
    2. 2. Hold the Licentiate of the Medical Council of Canada (LMCC), and
    3. 3. Have successfully completed training on the Alberta Mental Health Certificates.
    4. DD dash MM dash YYYY
      We will make every effort to complete your registration by this date. Note: We cannot issue a backdated practice permit.
    5. Applicant information

    6. (LMCC number ‐ not your candidate code)
    7. Current Psychiatry Postgraduate Training

    8. Other Psychiatry Postgraduate Training

      (if applicable)
    9. Current contact information

      (for internal CPSA use only)
    10. Additional information required

    11. Note: With the support of your Program Director, your Physician Extender Limited registration will continue for the duration of your program.

      Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
      Accepted file types: jpeg, jpg, png, pdf, tiff, Max. file size: 5 MB.
    12. Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
      Accepted file types: jpeg, jpg, png, pdf, tiff, Max. file size: 5 MB.
    13. Accepted file types: jpeg, jpg, png, tiff, pdf, Max. file size: 5 MB.
      Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
    14. Signature

    15. DD dash MM dash YYYY
    16. Please keep a copy of all documents for your records, and allow 30 days for processing this application. Note: We cannot guarantee a practice permit will be issued.
    17. Hidden

      Admin fields

      For CPSA use only
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    23. This field is for validation purposes and should be left unchanged.

    CPSA acknowledges we are on traditional lands of First Nations and Métis people. Through our work, we strive to respect, honour and celebrate the histories, languages and cultures of First Nations, Métis, Inuit and all First Peoples of Canada.