TPP Alberta | Medical Residents Registration Form - College of Physicians & Surgeons of Alberta

If you are already registered with TPP Alberta, you do not have to complete this form to re-order pads.

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Registrant information
Name (as to appear on the pad)*
First Middle inital(s) Last
Email*
*Please use CPSA verified email
Enter Email Confirm Email
Regulatory Authority License/Registration number*
Program Coordinator/Supervisor information
TPP Alberta may contact your supervisor for verification before your registration is processed.
Program Coordinator/Supervisor name*
First Last
Program Coordinator/Supervisor email*
Enter Email Confirm Email
Program Coordinator/Supervisor contact phone number*
Information for TPP pad
Residency program name*
Location of residency program (city)*
Phone number of residency program*
Name of Program Director*
First Last
Shipping information
Shipping address*
ATTENTION: NO PO BOXES or OUT OF PROVINCE addresses allowed. Home deliveries are to CPSA registered residential addresses only. A signature is required at time of delivery.

Suite # Street address City Postal code
Shipping address contact phone number*
Signature
Checking this box will confirm you have read the TPP Guide*
I confirm I have reviewed and understand the content in the TPP Guide.
Checking this box will act as your signature*
I confirm I am the registrant and that information in this form is accurate.
Special instructions
We collect and share the personal information in this form for the purposes of registering you in TPP Alberta. We may share your information with the printing and courier vendors for the purpose of producing the secure pads, OR with regulatory organizations as set out in CPSA Bylaws for TPP Alberta. If you have any questions about collecting your information, please contact TPP Alberta at TPP.info@cpsa.ab.ca, 780-969-4939 or toll-free at 1-800-561-3899.
Name
This field is for validation purposes and should be left unchanged.

Registrant information

Program Coordinator/Supervisor information

Information for TPP pad

Shipping information

Signature

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