POS_Application: Practice Setting (Regulated Owner)

Provision of Professional Services

Application: Approval of Practice Setting (Regulated Owner Practice Setting)
Practice Setting Information
Name of Practice Setting
Practice Setting Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Practice Setting Phone Number
Format: (000) 000-0000.
Practice Setting Email
Practice Setting Website Address
Ownership

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.
Designated Owner's Name

First NameLast Name
Designated Owner's HPA College
Full name of the HPA College the designated owner is registered with. Do not use abbreviations.
Designated Owner's Registration Number
Registration number assigned by the HPA College
Designated Owner's Phone Number
Format: (000) 000-0000.
Designated Owner's Email
You must provide the name of each practice setting owner. Do you have another owner to include in this application?
Owner's Name

First NameLast Name
Owner's HPA College
Full name of the HPA College this owner is registered with, if applicable. Do not use abbreviations.
Owner's Registration Number
Registration number assigned by the HPA College, if applicable.
You must provide the name of each practice setting owner. Do you have another owner to include in this application?
Owner's Name

First NameLast Name
Owner's HPA College
Full name of the HPA College this owner is registered with, if applicable. Do not use abbreviations.
Owner's Registration Number
Registration number assigned by the HPA College, if applicable.
Most Responsible Physiotherapist
Most Responsible Physiotherapist's Name

First NameLast Name
Most Responsible Physiotherapist's Registration Number
Registration number assigned by the College of Physiotherapists of Alberta
Most Responsible Physiotherapist's Email
A copy of this application, once submitted, will be emailed to the Most Responsible Physiotherapist at the email address above so they are aware of the application status.
File Upload: Agreement

Most Responsible Physiotherapist's signed CPTA Provision of Professional Services Agreement. Only PDF documents are accepted.
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File Upload: Certificate of Completion

Most Responsible Physiotherapist Module certificate of completion dated within the last two years. Only PDF documents are accepted.
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Acknowledgements
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I understand that:
As the Designated Owner, I certify and declare that:
Application Fee
Is this an initial application for the owner(s) listed on this application? The $250.00 application fee is waived for additional practice settings with the same owner(s). If the application fee applies, the College will provide email instructions for paying the fee online.
Submission
Submission Date

YearMonthDay
Designated Owner's Signature
Should be Empty:

Provision of Professional Services

Practice Setting Information

Ownership

Most Responsible Physiotherapist

Acknowledgements

Application Fee

Submission