Notification of Physician Address / Name Change
The College depends solely on submissions from members to keep its members' addresses and other contact information up-to-date. For members' protection, third-party change requests are not accepted and name changes must be accompanied by the appropriate legal documentation.
The College requires an office address for publication in the Annual Listing (Medical Register). This is the address that is available to the public when a physician's address is requested. Physicians who are hospital-based should supply their hospital departmental address. Home addresses will be used only for the confidential list maintained for the exclusive use of the College. Home telephone numbers are not released under any circumstances.
Please read the following before proceeding:
Address changes submitted by e-mail are acceptable if the e-mail is sent from the e-mail address the College has on record for the member. Please answer the appropriate questions below when submitting a change by e-mail. Submit e-mailed requests to registration@cpsns.ns.ca.
To submit name or address change information by mail or fax, please print a paper copy of this form, complete in legible handprinting , and mail or fax to the address at the bottom of this form.
The College must receive a Certificate of Name Change from the Registry of Joint Stock Companies before it can recognize a name change for a professional corporation. The name change notification section is at the bottom of this form.
Address Change Notification
Date change of address is to become effective: day / month / year
__________________________________________________________
Name (Please print full name with surname first):
__________________________________________________________
Signature:
__________________________________________________________
Registration Number:
__________________________________________________________
Office address:
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Office phone:
__________________________________________________________
Office fax:
_________________________________________________________
Home address:
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Home phone:
__________________________________________________________
Home fax:
__________________________________________________________
Preferred address for receipt of College correspondence:
Office address
Home address
Areas of the College for which this name change is to apply:
Registration
Professional corporation registry
Electronic Mail (e-mail) address for College correspondence:
______________@_______________________
Beginning in 2006, the College will distribute its member publications (newsletter, physician guidelines and policies, annual report) by e-mail and fax only. These documents will also be available on the College website or upon request. Would you prefer to receive publications by:
E-mail only (please provide below)
_________________________________________________
Fax only (please provide below)
_________________________________________________
E-mail and fax (please provide both below)
_________________________________________________
Name Change Notification
(Documented proof of name change must accompany this form)
Date change of name is to become effective: day / month / year
__________________________________________________________
Registration Number:
__________________________________________________________
Prior name (Please print full name with surname first):
__________________________________________________________
Change name to (Please print full name with surname first):
__________________________________________________________
Signature:
__________________________________________________________
Submit to:
Registration Department
College of Physicians and Surgeons of Nova Scotia
5005-7071 Bayers Road
Halifax, Nova Scotia
Canada
B3L 2C2
Phone: (902) 422-5823
Toll-free in Nova Scotia: 1 (877) 282-7767
Fax: (902) 422-5035
