Confirmation Of Retired Status - The Royal College Of Physicians printable pdf download

Confirmation

of Retired Status

If you are retired, or are about to become retired, please let us know. Just complete and return this form to the Royal

College Services Centre. As a retired Fellow, you retain the use of your designation and remain a member of the

Royal College. Should you return to practice, please let us know and we will change your membership category to

Active Fellow (note: Active Fellows must participate in the Maintenance of Certification Program and pay the

appropriate annual dues). Please note: to be eligible for Retired status, you must have relinquished your provincial

medical license. If you are retiring within the next three months, your form will be held for future processing based

on the retirement date indicated below. You will not be required to renew your Fellowship during this time.

Royal College I.D. No.: ______________

Name:_______________________________________

Declaration of Retired Status

By submitting this form, I declare that I am retired (or will be retired within the next three months) from all

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medical or health-related professional activities, and I no longer carry a license to practice through a

provincial/territorial Medical Regulatory Authority.

Fellows in part-time practice or reduced-scope practice (such as surgical assisting) for which a license is

required must continue to participate in the Maintenance of Certification (MOC) Program and are not eligible for the

Retired category.

I am not working part-time or on a restricted scope of practice license.

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Effective date of retirement:____________________

Signature:____________________________________

Date:_________________

As a Retired Fellow of the Royal College, you:

remain entitled to use the FRCPC or FRCSC designation,

•

continue to receive the Royal College’s e-newsletter, Dialogue and other timely communications,

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are eligible to participate in the Royal College’s $1 million per year awards and grants program, either as a

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nominator or recipient,

can influence the direction of specialty medicine by serving on committees and exam boards,

•

can stand for elected office, vote at the annual members’ meeting, and offer perspectives through surveys

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and committee activities,

are not required to participate in the Maintenance of Certification program, and

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pay no annual dues.

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Please note: Although retired Fellows are not required to participate in the MOC Program, you will continue to have

access to MAINPORT and given a retirement MOC cycle. If you return to practice and your Royal College status is

changed back to active within one year, your MOC cycle will continue from its original start date. If you return to

practice later than one year, you will be given a new active MOC Cycle, which will start on the date you return as an

active Fellow.

Contact information

To ensure you continue to receive member correspondence from the Royal College, please provide us with your email

and other contact information.

Email:_____________________________________

Residential Mailing Address:

Telephone: _____________________

Fax: _____________________

Please print and send by mail, email or fax.

Royal College Services Centre

Telephone: 1-800-461-9598 or 613-730-6243

Royal College of Physicians and Surgeons of Canada

Fax: 613-730-2410

774 Echo Drive, Ottawa ON (Canada) K1S 5N8

Email: membership@royalcollege.ca

royalcollege.ca

Confirmation Of Retired Status - The Royal College Of Physicians

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