Professional Corporation Application Form

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?*

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