Change of Most Responsible Physiotherapist (Non-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
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Designated Owner's Name* This field is required.For the purpose of this application and any authorization granted, the "designated" owner is the contact person between the College of Physiotherapists of Alberta and the owner(s) of the practice setting. The designated owner is expected to be knowledgeable of the regulatory responsibilities of registered physiotherapists and familiar with physiotherapy-related business operations.
First Name
Last Name
4
Designated Owner's Phone Number* This field is required.
Please enter a valid phone number.
5
Designated Owner's Email Address* This field is required.
example@example.com
6
PAST OR DEPARTING Most Responsible Physiotherapist's Name* This field is required.
First Name
Last Name
7
NEW Most Responsible Physiotherapist's Name* This field is required.
First Name
Last Name
8
NEW Most Responsible Physiotherapist's Registration Number* This field is required.
Registration number assigned by the College of Physiotherapists of Alberta
9
NEW Most Responsible Physiotherapist's Email Address* 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
10
File Upload: Agreement* This field is required.NEW 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.
Cancelof
11
File Upload: Certificate of Completion* This field is required.Provision of Professional Services Module. NEW most responsible 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.
Cancelof
12
As the designated owner, I agree to:* This field is required.
Positively enable the Most Responsible Physiotherapist and any other physiotherapists working at the practice setting named in this application to meet their professional responsibilities established in the College of Physiotherapists of Alberta's Standards of Practice, Code of Ethical Conduct and governing legislation.
13
As the designated owner, I agree to:* This field is required.
Positively enable the Most Responsible Physiotherapist to fulfil their obligations in the Provision of Service Agreement.
14
As the designated owner, I agree to:* This field is required.
Immediately inform the College of Physiotherapists of Alberta if the Most Responsible Physiotherapist named in this application ceases to be the most responsible physiotherapist at this practice setting.
15
As the designated owner, I agree to:* This field is required.
Within 30 days of the Most Responsible Physiotherapist's resignation, submit a Change of Most Responsible Physiotherapist Application to the College of Physiotherapists of Alberta.
16
As the designated owner, I agree to:* This field is required.
Advise the College of Physiotherapists of Alberta of any and all changes to the information collected on this application either before or after approval.
17
As the designated owner, I certify and declare that:* This field is required.
The information provided on this application is true.
18
Submission Date* This field is required.
Date
Year
Month
Day
19
Designated Owner's Signature* This field is required.
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