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

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

Registrant information

Name (as to appear on the pad):*

First Middle inital(s) Last

Regulatory Authority License/Registration #*

Preferred method of correspondence:*

Hard copy mail
Email

Information printed on pad

Residency program name:*

Location of residency program (city):*

Phone # of residency program:*

Name of Program Director:*

First Last

Shipping information

Pad delivery address:*

(NOTE: NO PO BOXES or OUT OF PROVINCE addresses allowed)
A signature is required at time of delivery.

Street Address City Postal code

Phone number for delivery location:*

Program Coordinator/Supervisor

TPP Alberta will contact your supervisor for verification before your registration is processed.

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Signature

Checking this box will act as your signature:*

I confirm I am the registrant and that information in this form is accurate.

Email*

Enter Email Confirm Email

*Please use CPSA verified email

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

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 TPPinfo@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

Information printed on pad

Shipping information

Program Coordinator/Supervisor

Signature

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