Physician Sponsorship Form

Please note this date is not guaranteed.

List all practice locations (name and address) where the applicant will practise following a successful assessment. (e.g., Clinic/Hospital/Long Term Care facility name and address)

*NOTE: Assessments that don’t include full scope (e.g. clinic only) may result in practice permit restrictions.
*If selecting a scope other than clinic, the sponsor needs to have an agreement with the provincial health agencies/providers prior to submitting this form. A non-exhaustive list of providers would include Alberta Health Services, Covenant Health and Recovery Alberta.

Please list three potential supervisors that meet our supervisor criteria outlined on our website. These supervisors must be informed that they are listed on this form before you submit it.

Name on approved Sponsor Application form

Contact email for general communications

Privacy Notice: This information is being requested under the authority provided by Section 8.2(3) of Schedule 21 of the Health Professions Act. CPSA collects, uses and/or discloses your personal information with your consent or as authorized or required by law and in accordance with our Privacy Statement. We collect and use your personal information in order to support the business of CPSA, specifically to protect the public and guide and regulate our members.

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

Providing your CPSA registration # will help us resolve your inquiry more efficiently.

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Applicant information

Supervisor information

Sponsor information & signature

Admin Fields

Question about sponsoring a physician?

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