Approval of Practice Setting (Regulated Owner)

1

Name of Practice Setting * This field is required.

Name of Practice Setting

2

Practice Setting Address* This field is required.

Street Address

Street Address Line 2

City

Province

Postal Code

Country

3

Practice Setting Phone Number* This field is required.

Please enter a valid phone number.

4

Practice Setting Email* This field is required.

example@example.com

5

Practice Setting Website Address* This field is required.

www.example.com

6

Designated Owner's Name* This field is required.For the purpose of this application and authorization granted, the "designated" owner is a regulated owner who will be the contact person between the College of Physiotherapists of Alberta and the owner(s) of the practice setting. The designated owner needs to be knowledgeable of the regulatory responsibilities of registered physiotherapists and familiar with physiotherapy-related business operations in the practice setting.

First Name

Last Name

7

Designated Owner's HPA College* This field is required.Name of HPA College the designated owner is registered with.

Provide College's full name and not abbreviations

8

Designated Owner's Registration Number* This field is required.

Registration number assigned by HPA College

9

Designated Owner's Phone Number* This field is required.

Please enter a valid phone number.

10

Designated Owner's Email* This field is required.

example@example.com

11

You must provide the name of each practice setting owner. Do you have another owner to include in this application?* This field is required.

YESNO

12

Owner's Name

First Name

Last Name

13

Owner's HPA CollegeName of HPA College this owner is registered with if applicable.

Provide College's full name and not abbreviations

14

Owner's Registration NumberRegistration number assigned by HPA College if applicable.

Registration number assigned by HPA College

15

You must provide the name of each practice setting owner. Do you have another owner to include in this application?

YESNO

16

Owner's Name

First Name

Last Name

17

Owner's HPA CollegeName of HPA College this owner is registered with if applicable.

Provide College's full name and not abbreviations

18

Owner's Registration NumberRegistration number assigned by HPA College if applicable.

Registration number assigned by HPA College

19

Most Responsible Physiotherapist's Name* This field is required.

First Name

Last Name

20

Most Responsible Physiotherapist's Registration Number* This field is required.

Registration number assigned by the College of Physiotherapists of Alberta

21

Most Responsible Physiotherapist's Email* This field is required.A copy of this application, once submitted, will be emailed to the Most Responsible Physiotherapist at the email address below so they are aware of the application status.

example@example.com

22

File Upload: Agreement* This field is required.Most Responsible Physiotherapist's signed Provision of Professional Service Agreement.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Only PDF documents are accepted.

23

File Upload: Certificate of Completion* This field is required.Most Responsible Physiotherapist Module. Physiotherapist's certificate of completion dated within the last two years.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Only PDF documents are accepted.

24