Temporary Practice in Alberta Application Form

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

Important

You must complete and submit this form 30-60 days before starting any temporary activity.

Applicant information

Name of applicant:*

Given name(s) Last name

Any previous names?*

No
Yes

Please list all previous names:*

Given name(s)	Last name

Email*

Enter Email Confirm Email

Phone number:*

Previous CPSA registration # (if applicable):

Gender:*

Female
Male

Birthplace:*

(Include country)

Date of birth (should be typed in the format mm/dd/yyyy, as in 03/15/2023):*

Address:*

Medical degree information

Medical Degree granted by (name of institution):*

Country institution is located in:*

Date of medical degree (mm-yyyy):*

Temporary registration information

Type of temporary registration you require:*

Note: CPSA provides 30-day registration for visiting clinicians and medical instructors, and 90-day registration for visiting learners.

Visiting clinician
Visiting learner
Visiting medical instructor

Name of person who is supporting you during your short duration activity:*

(e.g., Alberta registered physician, instructor or program director)

First Last

Start date (should be typed in the format mm/dd/yyyy, as in 03/15/2023):*

End date (should be typed in the format mm/dd/yyyy, as in 03/15/2023):*

Location of short duration activity:*

Phone # for location:*

Nature and purpose of short duration activity:*

Nature of contact or interactions with patients:*

Additional information required

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

Completed Sponsorship for Temporary Registration Form*

Have the person supporting your participation for temporary registration complete and return this form directly to you so you can upload it here.

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

Completed Registration Understanding and Acknowledgment - Visiting Instructor

Please save a copy of this agreement for your personal records.

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

Completed Registration Understanding and Acknowledgment - Visiting Learner

Please save a copy of this agreement for your personal records.

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

Completed Registration Understanding and Acknowledgment - Visiting Clinician

Please save a copy of this agreement for your personal records.

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

Completed Criminal Record Check or Police Certificate from your local authority:*

Note: we do not accept Vulnerable Sector Checks.

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

Request for a Certificate of Professional Conduct from the jurisdiction in which you are currently practising*

Note: the jurisdiction will send this certificate directly to CPSA.

Yes, I've made this request

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)*

Please retain a copy of all documents submitted for your records.

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 reviewed.

Once we review your application we will inform you if you have been successfully added to CPSA's Courtesy Register. Please note there is no guarantee we'll issue a practice permit.