Physician Extender (Limited) 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
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,
3. 2. Hold the Licentiate of the Medical Council of Canada (LMCC), and
5. 3. Have successfully completed training on the Alberta Mental Health Certificates.
Date Physician Extender Limited 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
Gender:*

Female

Male
CPSA registration #:*
Licentiate of the Medical Council of Canada (LMCC) #:*

(LMCC number ‐ not your candidate code)
Year LMCC obtained:*
Current Psychiatry Postgraduate Training
Dates (mm-yyyy to mm-yyyy):*
Name of program:*
University:*
Other Psychiatry Postgraduate Training
(if applicable)
Dates (mm-yyyy to mm-yyyy):
Name of program:
University:
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*
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.
Completed and witnessed Registration Understanding and Acknowledgment*
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.
Copy of your LMCC certification (wallet card or wall certificate)*
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.
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
Email*
Enter Email Confirm Email
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.
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Admin fields
For CPSA use only
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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 Psychiatry Postgraduate Training

Other Psychiatry Postgraduate Training

Current contact information

Additional information required

Signature

Admin fields

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