Approval of Practice Setting (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

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

Website Address* This field is required.

www.example.com

6

Facebook* This field is required.If no Facebook page enter Not Applicable.

Facebook Page

7

Twitter* This field is required.If no Twitter handle enter Not Applicable.

Twitter Handle

8

LinkedIn* This field is required.If no LinkedIn profile enter Not Applicable.

LinkedIn Profile

9

Instagram* This field is required.If no Instagram handle enter Not Applicable.

Instagram Handle

10

TikTok* This field is required.If no TikTok account enter Not Applicable.

TikTok Account

11

YouTube* This field is required.If no YouTube account enter Not Applicable.

YouTube Account

12

Do you have additional social media accounts to report?* This field is required.

YESNO

13

Additional Social Media Accounts

14

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 needs to be knowledgeable of the regulatory responsibilities of registered physiotherapists and familiar with physiotherapy-related business operations.

First Name

Last Name

15

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

Please enter a valid phone number.

16

Designated Owner's Email* This field is required.

example@example.com

17

File Upload: Certificate of Completion* This field is required.Provision of Professional Services Module. Designated Owner'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.

18

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

19

Owner's Name

First Name

Last Name

20

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

YESNO

21

Owner's Name

First Name

Last Name

22

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

First Name

Last Name

23

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

Registration number assigned by the College of Physiotherapists of Alberta

24

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

25

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.

26

File Upload: Certificate of Completion* This field is required.Provision of Professional Services Module. 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.

27

File Upload: Contract* This field is required.Sample contract between physiotherapy staff and practice setting.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB