Additional SPA Supervisor Names - College of Physicians & Surgeons of Alberta

Applicant's name(Required)

First name Last name

CPSA Registration number(Required)

Supervisor Details

Applicants must be supervised while in their Supervised Practice Assessment (SPA). We are requesting additional SPA supervisor name(s) because we are unable to use the supervisor(s) listed on the original Physician Sponsorship Form. Please list at least one potential supervisor who meets the supervisor criteria outlined on our website.

The supervisor(s) must be informed that they are listed on this form before you submit it.

Supervisor #1(Required)

First name Last name

Email(Required)

Supervisor #2 (Optional)

First name Last name

Supervisor #3 (Optional)

First name Last name

Signature

NOTE: CPSA will only accept sponsorship request forms signed by an approved sponsor.

Sponsor's signatory name(Required)

First name Last name

Email(Required)

Date(Required)

Checking this box will act as your signature:(Required)

I have reviewed the information in this form, and I confirm it is accurate.

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.