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 ad-
dress 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: [email protected]
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
___________________________________________________ Postal code
___________________________________________________
Phone number
___________________________________________________ Phone number
___________________________________________________
Fax number
___________________________________________________ Fax number
___________________________________________________
q Check here if this change also applies to your Medicine q Check here if this change also applies to your Medicine
Professional Corporation registered office address
Professional Corporation business 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)
___________________________________________________
___________________________________________________