Change Of Address Notification
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1Change of Address Notification
This form is provided for members to notify the College of any change in address
The College’s register must contain your
different from your practice address. It
tice address, you must notify the College
in writing within 30 days of the change.
current mailing address, email address,
is NOT available to the public, unless
and your primary practice address.
you decide to use your primary practice
address as your mailing address. Your
And we have made it easier for you to
PLEASE MAIL, EMAIL OR FAX
primary practice address is available to
do that - you can now change your
THIS FORM TO:
the public.
address and update your information
Membership Services
in the Members’ section of our website
If not in practice, you may check the
College of Physicians and Surgeons
at
“not in practice” but current mailing
of Ontario
address and email address must always
You can also send us the change of
80 College Street
be provided.
address form below. Please mail, fax, or
Toronto, ON, M5G 2E2
email it to the College.
The College also uses your email address
Email: membership@cpso.on.ca
for some communications. Your email
Your mailing address is the address
Fax: (416) 967-2643
address is NOT available to the public.
you would prefer the College use to
communicate with you and may be
If you change your mailing, email or prac-
UPDATED ADDRESS INFORMATION
(please print legibly)
CPSO Registration Number ___ ___ ___ ___ ___ ___
Surname
_______________________________________________________________________________________________________________
Given Names
_______________________________________________________________________________________________________________
Name of your Medicine Professional Corporation (if applicable)
_______________________________________________________________________________________________________________
PRIMARY PRACTICE ADDRESS:
MAILING ADDRESS:
q
q
Not in practice
Same as primary practice address
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Postal code
Postal code
__________________________________________________
__________________________________________________
Phone number
Phone number
__________________________________________________
__________________________________________________
Fax number
Fax number
__________________________________________________
__________________________________________________
q
q
Check here if this change also applies to your Medicine
Check here if this change also applies to your Medicine
Professional Corporation business address
Professional Corporation registered office address
Effective date
EMAIL ADDRESS:
_________________________________________________
__________________________________________________
Signature
_________________________________________________
IMPORTANT FOR SECURITY
– please provide the following information:
Date of birth
Name of base hospital during your Internship (PGY1)
__________________________________________________
__________________________________________________
September 2014
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