Change of Address Notification
This form is provided for members to notify the College of any change in address
Each member is required under College
by-law to provide his or her primary
practice address, preferred mailing address, and email address.
The primary practice address is public
and is entered in the College’s public
register in the website. The email address is not public. The mailing address
is also not public, unless the member
chooses to use the primary practice
address for the mailing address.
If not in practice, the member may
check the ‘not in practice’ box, but current mailing address and email address
must always be provided.
Every change of address – practice,
mailing or email – must be reported to
the College in writing within 30 days of
the change.
Updated address Information
Please mail, email or fax
this form to:
Membership Services
College of Physicians and Surgeons
of Ontario
80 College Street
Toronto, ON
M5G 2E2
Email: [email protected]
Fax: (416) 967-2643
(please print legibly)
CPSO Registration Number ___ ___ ___ ___ ___ ___
Surname
________________________________________________________________________________________________________________
Given Names
________________________________________________________________________________________________________________
primary practice address:
Not in practice q
mailing address:
Same as primary practice address q
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Postal code
___________________________________________________
Postal code
___________________________________________________
Phone number
_________