Physician Extender (Limited) Form

  • 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. Date Format: 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

      Note: With the support of your Program Director, your Physician Extender Limited registration will continue for the duration of your program.
    11. 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.
    12. Accepted file types: jpeg, jpg, png, tiff, pdf.
      Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
    13. Signature

    14. Date Format: DD dash MM dash YYYY
    15. 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.