Resignation - College of Alberta Denturists

Last name *

First name *

Registration number *

Current address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone number *

New contact information

The College must be able to contact you for the next two years. Please provide any updated contact information to the College if it is changing subsequent to your resignation.

New address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

New phone number *

New email *

Registration Change

Reason for resignation (please choose one) *

Other reason *

Effective date *

Should you be eligible for a refund of a portion of your practice permit fees, to whom should these be payable? *

Name of person/company to whom refund should be issued *

Address of person/company to whom a refund should be issued *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Patient Records

What type of employment did you most recently have? Please check all that apply. *

Clinical practice
Educator

Are/were you the owner of any clinic(s)? *

Did you sell the practice? *

Please confirm that the patient records stay at the clinic. *

I acknowledge that all patient records remain at the clinic(s) at which I have ceased employment.

Who is the new owner? *

Are the patient records remaining at the clinic? *

Who is the custodian of your patient records? *

Where are the patient records being stored? *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Who is the new custodian of the patient records? *

Where are the patient records being stored? *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Declarations

You may be contacted by the College for further information.

I understand that I must hold a provisional or general practice permit with the College in order to practice the profession of denturism in Alberta. *

I understand that the practice of denturism is not restricted to only providing direct patient services, but also includes the design, construction, repair, alteration and fitting of any complete or partial denture for the purpose of restoring and maintaining function and appearance; teaching, managing or conducting research in the science, techniques and practice of denturism; or providing restricted activities authorized by the Denturists Profession Regulation. *

I understand that I may not use the protected titles of denturist or registered denturist once I am no longer regulated by the College. *

I acknowledge that I am responsible for compliance with the Continuing Competence Program for the time that I was a regulated member with the College of Alberta Denturists. *

I understand that the qualifications for eligibility for registration as a regulated member may change in the future without notice. *

I understand that it is unlawful to practice denturism in Alberta without being registered with the College of Alberta Denturists and that penalties may be enforced, as per the Health Professions Act, should I act unlawfully in this manner. *

I understand that as per section 48(1) of the Health Professions Act, a person who meets the requirements of s. 46(1) [mandatory registration] and does not comply with a request to register with the College under s. 46(2) is guilty of an offense. *

I understand that for two years, following my change to unregulated status, a complaint may be lodged against me through the legislated complaint process. *

I understand that the collection, use and disclosure of my personal information will be handled in accordance with applicable privacy policies and laws. *

I will immediately advise the College, in writing, if there is any change to any of the information contained in this application. *

I will immediately advise the College, in writing, should I wish to return to practice. *

I verify that all information contained in this application, including these declarations, is complete and accurate. I understand that a false or misleading statement, an omission or misrepresentation may have impact on my future registration as a denturist in Alberta. *