Professional Corporation Application Form

Comments

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

Section 108 – Health Professions Act

Name of Professional Corporation (PC):*

Registered office address:*

This must be an Alberta address

Street Address City/Town Postal code

Preferred address to receive CPSA registered mail?*

Registered office address
Alternate address

Alternate address:*

Street Address City/Town Postal code

List all voting shareholders of this PC who are registered with CPSA:*

*Click the + to add additional shareholders

Full name	Email	Confirm email	Address

List all non-voting shareholders of this PC (i.e., spouse, child or common-law partner of a voting shareholder):

*Click the + to add additional non-voting shareholders

Full name	Address

List all persons registered with CPSA who are directors of this PC:*

*Click the + to add additional directors

Full name	Address

Please check the box to confirm each of the following:*

There are no restrictions on the business which would restrict this PC in providing medical services to the public.

Please check the box to confirm each of the following:*

This PC has, by law or by virtue of its incorporating documents, the capacity to carry out on the business and exercise the powers set out in the Health Professions Act.

Please check the box to confirm each of the following:*

There are no voting shares of this PC that are or intended to be subject to a voting trust or any other type of agreement that is contrary to Section 111 of the Health Professions Act.

Please check the box to confirm each of the following:*

This PC is in good standing with the Registrar of Corporations under the Business Corporations Act.

Please check the box to confirm each of the following:*

Each of the persons practising medicine on behalf of the PC is a regulated member of CPSA.

Please check the box to confirm each of the following:*

All physician shareholders of this PC have authorized me to list their names on this form.

Please check the box to confirm each of the following:*

I understand CPSA will notify all physician shrareholders that this PC is active.

Attach a copy of the PC's Certificate of Incorporation certified correct by the Registrar of Corporations:*

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

Max. file size: 20 MB.

Signature

Checking this box will act as your signature:*

As a physician registered with CPSA and a director of this professional corporation or as an authorized representative of this professional corporation, I confirm that the information in this form is accurate.

Name*

First Last

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

Please identity the email address where you would like us to send the completed "Form F".*

Enter Email Confirm Email

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 processed.