Status & Name Changes

Status Changes

A change in registration status may be requested using the 2018 Status Change Package. The form must be completed and printed, and a signed copy submitted to the ACSLPA office by mail, fax or scanned email. Please refer to the 2018 ASCLPA Fee Schedule for information regarding applicable fees/refunds associated with status changes.

Name Changes

Registrants may inform us of a name change using the interactive form below. Upon completion of the form, click “OK” to send your updated information directly to the ACSLPA office. 

Note: A copy of official documentation providing proof of the change must be submitted to the ACSLPA office to complete the process. Acceptable documents include government-issued marriage, name change from Vital Statistics or a certificate of divorce. A driver's licence is not acceptable as official documentation.

Fax:   780-408-3925
Mail:   #209, 3132 Parsons Road, Edmonton, AB T6N 1L6

  • Member Request for a Name Change

  • This form will be submitted automatically to ACSLPA upon completion. You will not be able to submit the form without completing all required fields

  • Member Information

  • As currently on file with ACSLPA

  • Name Change

  • * If requesting a name change, supporting documentation is required (i.e. government-issued marriage certificate, driver's license or other official documentation providing proof of name change). Please fax to the ACSLPA office at 780-408-3925 or submit by email to

  • Your new practice permit reflecting your name change will be available on your profile once the change has been made at the ACSLPA office.

  • By submitting this form, I certify and declare that the above information is true and accurate.


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