PRIVATE & CONFIDENTIAL

CERTIFICATE OF PROFESSIONAL CONDUCT

ISSUED TO: REGARDING:

1. Graduated from:

2. Year graduated:

3. Qualifications:

4. Registration number:

5. Date certificate of registration issued:

6. Status of registration:

7. Registration expiry date:

8. Licence status:

9. History of Disciplinary Action including Censure as recorded on the Register1:

10. History of action by the Investigation Committee pursuant to Section 47(1)(d), (e) or (f) of The
Medical Act which the Investigation Committee has directed the Registrar to record on the
Certificate of Professional Conduct:1,2

11. Current inquiries by the Investigation or Complaints Committees as at the date of issue of this
certificate:

12. Any other information respecting the member which has been reported to the College and which is
deemed by the Registrar to be relevant to the practice of medicine:

Date of Issue:
Not official without signature of Registrar and impression of College seal
No further entries below

1
The By-Laws of the College of Physicians and Surgeons of Manitoba previously permitted a member or former member in certain circumstances to make application to the executive
committee for an order: (a) that the member is entitled to have issued a certificate of professional conduct without reference to a censure; and (b) the member is entitled to have issued a
certificate of professional conduct without reference to action taken by the investigation committee being recorded on the certificate of professional conduct.
2
Letters of advice which are the opinion of the investigation committee are not included.

COPC Sample.doc