Professional Corporation Information Form (PCIF) - College of Physicians & Surgeons of Alberta

Name of Professional Corporation (PC):*

Professional Corporation #:*

Registered office address:

Street Address City/Town Postal code

Alternate address:

Street Address City/Town Postal code

Preferred address to receive CPSA registered mail?

Registered office address
Alternate address

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

*Click the + to add additional shareholders

NOTE: For PCs with multiple shareholders, only the designated physician will see the PC renewal information. Once completed, the PC permit and receipt will be posted to the practice profiles of ALL shareholders.

CPSA will contact you to collect payment for the addition of these voting physician shareholders.

Last name	First name	Number and Class of shares held

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

Last name	First name	Address

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

*Click the + to add additional directors

Last name	First 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.

Signature

Checking this box will act as your signature:*

As a physician registered with CPSA and a director of this professional corporation, I confirm that information in this form is accurate.

Name*

First Last

Email*

Enter Email Confirm Email

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