Consent for Letter of Standing Consent for Letter of Standing I, Dr. Doctor Name(Required)request that a letter of standing be forwarded to:Organization Name(Required)Attention(Required)Name of IndividualSalutation(Required) Dr. Mr. Mrs. Ms. Address(Required) Street Address Address Line 2 City Province Postal Code Email(Required) Letter format required(Required) Hard copy letter (via Canada Post) Email Understandings and ConsentI Give Consent(Required) I understand that by signing this form, I give consent to the College of Chiropractors of Alberta (CCOA) to disclose the following information to the organization/individual identified above:• Personal and contact identifiers (name, licence number, and email address)• Registration information (current register, registration history, terms, conditions and restrictions on licensure)• Complaints (open)• Investigations (in progress)• Disciplinary actions (dates, particulars, findings, remedies or sanctions)• Confirmation that professional liability protection is in place I understand why(Required) I understand why I have been asked to disclose this information and am aware of the risks or benefits of consenting or refusing to disclose this information. I understand that(Required) I understand that processing this request may take up to 15 business days. Full Name(Required) First Last CCOA Licence Number(Required)Email(Required) Phone(Required)Date(Required) MM slash DD slash YYYY Signature(Required)(An electronic signature is acceptable if this form is submitted via the email address on your member profile) Questions? Please feel free to contact registration@theccoa.ca.
