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 )
___________________________________________________ ___________________________________________________
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DIALOGUE ISSUE 3 , 2017