Dialogue Volume 13 Issue 2 2017 - Page 78

Change of Address Notification This form is provided for members to notify the College of any change in address The College’s register must contain your current mailing address, email address, and your primary practice address.  And we have made it easier for you to do that - you can now change your address and update your information in the Members’ section of our website at www.cpso.on.ca You can also send us the change of address form below. Please mail, fax, or email it to the College. Your mailing address is the address you would prefer the College use to communicate with you and may be different from your practice address. It is NOT available to the public, unless you decide to use your primary practice address as your mailing address. Your primary practice address is available to the public.  If not in practice, you may check the “not in practice”  but current mailing address and email address must always be provided. The College also uses your email ad- dress for some communications. Your email address is NOT available to the public.   Updated address Information If you change your mailing, email or practice address, you must notify the College in writing within 30 days of the change. 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: membership@cpso.on.ca Fax: (416) 967-2643 (please print legibly) CPSO Registration Number ___ ___ ___ ___ ___ ___ Surname ________________________________________________________________________________________________________________ Given Names ________________________________________________________________________________________________________________ Name of your Medicine Professional Corporation (if applicable) ________________________________________________________________________________________________________________ primary practice address: Not in practice q mailing address: ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ Same as primary practice address q Postal code ___________________________________________________ Postal code ___________________________________________________ Phone number ___________________________________________________ Phone number ___________________________________________________ Fax number ___________________________________________________ Fax number ___________________________________________________ q Check here if this change also applies to your Medicine q Check here if this change also applies to your Medicine Professional Corporation registered office address Professional Corporation business address Effective date __________________________________________________ Email address: Signature __________________________________________________ ___________________________________________________ Important For security – please provide the following information: 78 Date of birth Name of base hospital during your Internship (PGY1) ___________________________ ‘X[YH\YH  M—