Credit Card Payment Authorization

PLEASE NOTE: In order to comply with Payment Card Industry Data Security Standards, the College is not able to accept credit card payments by email or telephone. Faxed credit card payments will only be accepted if remitted directly to the Finance Department at (416) 967-2654.

For clarity, please complete this form electronically.

CPSO Number:

Given Name(s):

Surname:

Street Address: City:

Province/State: Postal/Zip Code: Country:

Email Address: Phone Number:

$1725.00 - 2020 Renewal Fee - Independent Practice Certificate

$431.25 - 2020 Late Payment Penalty - Renewal of Independent Practice Certificate

$345.00 - 2020 Renewal Fee - Postgraduate Education Certificate

College Assigned ID (for Corporation Fees Only)

$175 - Renewal Fee - Certificate of Authorization (Medical Corporation)

$400.00 - Application Fee - Certificate of Authorization (Medical Corporation)

Other (Please Specify) Amount

I authorize The College of Physicians and Surgeons of Ontario to charge to my :

Account Number

- - -Expiry Date (MM/YY)

/ Cardholder Signature

Cardholder Name (Print)

Date

for Membership Fees and Corporation Fees