Registration Department Suite 400 - 175 Western ParkwayBedford, Nova Scotia Canada B4B 0V1Phone: (902) 422-5823 Toll –free: 1-877-282-7767 Fax: (902) 422-5035 Email: registration@cpsns.ns.ca www.cpsns.ns.ca

Letter of Intent As part of your application for licensure in Nova Scotia, you are required to provide information related to your practice intentions in Nova Scotia. Please complete the below form for this requirement.

Office/Hospital telephone number:

Home Contact Information in Nova Scotia

Mailing address:

Home phone number: Cell phone number:

If you do not have a home address in Nova Scotia, please provide an explanation (for instance, if you have a main practice in another jurisdiction and will maintain a mailing address in that jurisdiction, please provide these details below):

Mailing address if different than Nova Scotia home address:

Fax:

Signature: Date:

Name:

Intended start date: End date (if applicable):

A detailed description of your intended scope of practice in Nova Scotia (including approximate hours of practice):

Practice Contact Information in Nova Scotia

Office/Hospital address:

Scope of practice within the last 3 years: