REG_Release of Regulatory History Request Form

Release of Regulatory History Request Form
Applicant name*
Other last name(s) if applicable
Email*
(Same email that is on file with the College of Physiotherapists of Alberta)
Registration number*
(With the College of Physiotherapists of Alberta)
Date of Birth*

MonthDayYear
Date
Authorization to release regulatory information
Name of regulatory authority*
How the regulatory history form should be provided to the regulatory authority:*

EmailMail
Email address*
Mailing address*
Information Reported on Regulatory History Form
The College of Physiotherapists of Alberta will provide the following information directly to the regulatory authority named.
1. Member/applicant's full name.
2. Member/applicant's other last name(s), if applicable.
3. Member/applicant's date of birth.
4. Dates of registration and current registration status/license type held.
5. Details of current involvement in an inquiry or proceeding respecting their practice, conduct, competence, incapacity of professionalism as a physiotherapist in Alberta. An inquiry or proceeding can include, but is not limited to, appearance before a committee or panel, investigation, alternative complaint resolution process, hearing, or appeal.
6. Details of previous involvement in an inquiry or proceeding respecting their practice, conduct, competence, incapacity of professionalism as a physiotherapist in Alberta which resulted in actions. An inquiry or proceeding can include, but is not limited to, appearance before a committee or panel, investigation, alternative complaint resolution process, hearing, or appeal.
7. Details of any reported criminal charges and/or convictions as well as any other outstanding charges against this individual.
Declaration statement
I authorize the College of Physiotherapists of Alberta to provide the "Information Reported On Regulatory History Form" to the regulatory authority named above. I understand and accept that the College of Physiotherapists of Alberta will provide full disclosure of any and all information relevant to my application for registration as a physiotherapist with the regulatory authority.*
Submission
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Release of Regulatory History Request Form

Authorization to release regulatory information

Information Reported on Regulatory History Form

Declaration statement

Submission