Application to Change Status to Researcher Application to Change Status to Researcher Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Practice Permit #:(Required)Clinic address:(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Clinic phone:(Required)Clinic fax:Decribe research activity (type, number of hours per week on research, etc.)(Required)Hours in active practice per week:(Required)Research affiliation:(Required)(name of university)The following supporting documentation must be submitted with this application(Required) Letter from Dean or Chair of post secondary institution confirming full time student research or faculty research status Proof of current enrollment in a full-time residency program Upload supporting documentation here:(Required)Max. file size: 64 MB. I declare that the information provided is true and correct to the best of my knowledge.(Required)SignatureDate signed:(Required) MM slash DD slash YYYY Questions? Please feel free to contact registration@theccoa.ca.
