Change 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 current mailing address, email address, and your primary practice address.
And we have made it easier for you to do that- you can now change your address and update your information in the Members’ section of our website at www. cpso. on. ca
You can also send us the change of address form below. Please mail, fax, or email it to the College.
Your mailing address is the address you would prefer the College use to communicate with you and may be different from your practice address. It is NOT available to the public, unless you decide to use your primary practice address as your mailing address. Your primary practice address is available to the public.
If not in practice, you may check the“ not in practice” but current mailing address and email address must always be provided.
The College also uses your email address for some communications. Your email address is NOT available to the public.
If you change your mailing, email or practice address, you must notify the College in writing within 30 days of the change.
Please mail, email or fax this form to:
Membership Services College of Physicians and Surgeons of Ontario 80 College Street Toronto, ON, M5G 2E2
Email: membership @ cpso. on. ca Fax:( 416) 967-2643
Updated address Information( please print legibly)
CPSO Registration Number ___ ___ ___ ___ ___ ___
Surname ________________________________________________________________________________________________________________
Given Names ________________________________________________________________________________________________________________
Name of your Medicine Professional Corporation( if applicable) ________________________________________________________________________________________________________________
primary practice address:
Not in practice q
___________________________________________________ mailing address:
Same as primary practice address q
___________________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________
Postal code ___________________________________________________
Phone number ___________________________________________________
Fax number ___________________________________________________
q Check here if this change also applies to your Medicine Professional Corporation business address
___________________________________________________
Postal code ___________________________________________________
Phone number ___________________________________________________
Fax number ___________________________________________________
q Check here if this change also applies to your Medicine Professional Corporation registered office address
Effective date __________________________________________________
Signature __________________________________________________
Email address:
___________________________________________________
Important For securiTY – please provide the following information: Date of birth
Name of base hospital during your Internship( PGY1)
___________________________________________________ ___________________________________________________
78
Dialogue Issue 2, 2017