Annual Renewal for a Certificate
of Authorization for a Health
Profession Corporation
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Instructions and Checklist
Annual Renewal forms for a Certicate of
Authorization for a Health Profession Corporation
(“Corporation”) that are incomplete will be
returned.
The $282.50 (includes HST) fee accompanying
the application form is non-refundable. The fee
must be paid by a credit card accepted by
CNO.
INSTRUCTIONS
Prior to submitting your Annual Renewal Form,
please ensure that the following criteria have
been met:
1.
A Director (must be a member of the College)
authorized to sign on behalf of the Corporation has
signed the Annual Renewal Form (Part A).
2. e same Director that signed the Annual Renewal
Form has also signed the required Declaration
(Part B).
3. Each NEW Director (must be members of the College)
of the Corporation has executed an Undertaking in
Part C. “New Director” is defined as a member who
has not previously completed an Undertaking in Part
C in respect of the Corporation. Please make as many
copies of the form as required.
4. Each NEW Shareholder (must be members of the
College) of the Corporation has executed an
Undertaking in Part D. “New Shareholder” is defined
as a member who has not previously completed an
Undertaking in Part D. Please make as many copies of
the form as required.
5. In completing the Annual Renewal Form, if more
space is required, attach additional pages labelled
appropriately.
CHECKLIST
The Annual Renewal Form for a Certicate of
Authorization for a Health Profession Corporation
is considered incomplete without the following
enclosures:
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1.
S igned Annual Renewal Form completed by the
same Director of the Corporation who signed the
Declaration. (See item 3.)
2. F
ee in the amount of 282.50 (includes HST)
to be paid when CNO calls you.
3. D
eclaration by a Director of the Corporation
signed not more than 15 days before the Annual
Renewal Form is submitted to the Executive
Director.
4. Certied cop
y of a corporation prole report
issued by the Ministry of Government and
Consumer Services (or a service provider under
contract to the Ministry) not more than 30 days
before the application is submitted to the
Executive Director, which indicates that the
Corporation is active
5. U
ndertaking in Part C to be completed by each
NEW Director of the Corporation.
6. U
ndertaking in Part D to be completed by each
NEW Shareholder of the Corporation (excluding
Director(s) who have completed Part C).
APR 2021
2021-37
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PART A
ONTARIO CORPORATION NO. ISSUED BY MINISTRY
Annual Renewal for a
Certificate of Authorization for
a Health Profession
Corporation
1
a)
NAME OF HEALTH PROFESSION CORPORATION
Note: e name of the Corporation must comply with the requirements of s.1 of Ontario Regulation 39/02 of the Regulated Health
Professions Act, 1991.
1
b)
CERTIFICATE OF AUTHORIZATION NUMBER
2)
BUSINESS ADDRESS OF HEALTH PROFESSION CORPORATION
I I
I I I
I I I
STREET SUITE
CITY PROVINCE POSTAL CODE
TEL FAX E-MAIL (optional)
3)
NAME(S) OF SHAREHOLDER(S) AS OF THE DAY THE APPLICATION IS SUBMITTED (must be a member of the College) AND HIS/HER
BUSINESS ADDRESS, BUSINESS TELEPHONE NUMBER AND REGISTRATION NUMBER WITH THE COLLEGE AS OF THAT DAY.
I
I II
I II
I II II
I II II
II
College Registration #
Last Name Given Names (underline one commonly used)
Business Address (Street) Suite
City Province Postal Code
Telephone Fax E-Mail
Director Officer
Provide Title of Office
I
College Registration #
I II
I II
I II II
I II II
II
Last Name Given Names (underline one commonly used)
Business Address (Street) Suite
City Province Postal Code
Telephone Fax E-Mail
Director Officer
Provide Title of Office
I
I II
I II
I II II
I II II
II
College Registration #
Last Name Given Names (underline one commonly used)
Business Address (Street) Suite
City Province Postal Code
Telephone Fax E-Mail
Director Officer
Provide Title of Office
(Attach additional pages appropriately labelled, if necessary.)
FOR OFFICE USE ONLY Date Received: Certicate No.: Date Issued: Date Denied:
APR 2021
2
2021-37
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I
I II
I II
I II II
I II II
II
College Registration #
Last Name Given Names (underline one commonly used)
Business Address (Street) Suite
City Province Postal Code
Telephone Fax E-Mail
Director Officer
Provide Title of Office
4)
NAME(S) OF INDIVIDUAL(S) (must be a member of the College) WHO WILL PRACTISE ON BEHALF OF THE CORPORATION, INCLUDING
ALL SHAREHOLDERS AND NURSING EMPLOYEES OF THE CORPORATION, AS OF THE DAY THE ANNUAL RENEWAL WAS SUBMITTED.
COLLEGE REGISTRATION # FULL NAME
5)
THE CORPORATION PRACTISES AND/OR CARRIES ON BUSINESS IN THE FOLLOWING LOCATION(S):
I
I II
II
II
I
I II
II
II
I
I II
II
II
I
I II
II
II
I
I II
II
II
I
I II
II
II
I
I II
II
II
Street Suite
City Postal Code Business Phone
Street Suit
e
City Postal Code Business Phone
Street Suit
e
City Postal Code Business Phone
Street Suit
e
City Postal Code Business Phone
Street Suit
e
City Postal Code Business Phone
Street Suit
e
City Postal Code Business Phone
Street Suit
e
City Postal Code Business Phone
2021-37
APR 2021
3
6)
PLEASE PROVIDE A BRIEF DESCRIPTION OF THE PROFESSIONAL ACTIVITIES CARRIED OUT BY THE CORPORATION.
Note: e Corporation cannot carry on, and cannot plan to carry on, any business that is not the practice of nursing or activities related or ancillary
to the practice of nursing (Regulation 39/02, subparagraph 6(ii) of subsection 2(1)).
I confirm that the information contained in this Certificate of Authorization Renewal Form for a Health
Professional Corporation is complete and accurate.
I I
Signature of Officer/Director authorized to sign on behalf of the Corporation Date
I I
Please print name College Registration Number
Payment information
1. Submit your completed form to CNO
2. Once we have received your form, we will call you to collect the fee
3. The fee must be paid by credit card
Please do not include your credit card information with this form. Please do not contact CNO to provide
payment; we will notify you once we have received your form.
HST #: R106953904
APR 2021
4
2021-37
PART B
Declaration
TO BE EXECUTED BY THE DIRECTOR SIGNING PART A
I,
[Insert Full Name of Nurse]
, a director of
[Insert Full Name of Health Profession Corporation (“Corporation”)]
,
do hereby certify that the following statements are true:
1.
I am a member of the College of Nurses of O
ntario holding Certificate of Registration No. ,
and Certificate of Authorization No. .
2. I am a director of the Corporation and have the authority to apply for the renewal of the Certificate of
Authorization.
3. e Corporation is in compliance with section 3.2 of the Business Corporations Act (Ontario) as of the date
this Declaration is signed.
4. e Corporation does not plan to carry on, and will not carry on, any business that is not the practice of
nursing, or an activity related or ancillary to the practice of that profession.
5. ere has been no change in the status of the Corporation since the date of the certificate of status enclosed
with the Annual Renewal for a Certificate of Authorization that accompanies this Declaration.
6. e information contained in the Annual Renewal for a Certificate of Authorization that accompanies this
Declaration is complete and accurate as of the day this Declaration is declared.
(Signature of Declarant) (Date)
2021-37
APR 2021
5
PART C
Undertaking
TO BE EXECUTED BY EACH NEW DIRECTOR ONLY
Each new Director of the Health Profession Corporation is required to execute a separate Undertaking.
I,
Name of Director
, a member of College of Nurses of Ontario
(“College”) and a shareholder of
Name of Corporation (“Corporation”)
UNDERTAKE TO
THE COLLEGE AS FOLLOWS:
1.
I accept professional responsibility for any act or omission of the Corporation that would be professional
misconduct if such act or omission had been committed or omitted by a member of the College.
2. I will ensure that the Corporation does not do or cause to be done, or omit or cause to be omitted, anything that
would be professional misconduct if done or omitted to be done by a member of the College.
3. I will ensure that the Corporation does not engage in the practice of nursing, or any activity related or ancillary to
the practice of that profession, unless it maintains a valid Certificate of Authorization issued by the College.
4. I will ensure that the Corporation does not practise under any name other than the name of the Corporation, a
practice name previously approved by the College for use by a shareholder of the Corporation or a name permitted
by Regulation.
5. I will ensure that the Corporation complies with the Regulated Health Professions Act, 1991, the Nursing Act, 1991,
the regulations made under those Acts, and the bylaws of the College.
6. I will ensure that the College is notified immediately of any change in shareholders of the Corporation and that any
future shareholder of the Corporation execute and file with the College, within ten (10) days of becoming a
shareholder of the Corporation, an Undertaking in a form approved by the College.
7. I will ensure that the College is notified of any changes to practice locations of the Corporation as soon as they
occur.
8. I will ensure that the College is notified within ten (10) days if I cease to be a director of the corporation.
9. I acknowledge that a breach of this Undertaking may result in referral of specified allegations of professional
misconduct against me to the Discipline Committee arising out of my failure to abide by any of the terms of this
Undertaking.
10. I acknowledge having been advised to obtain independent legal advice prior to signing this Undertaking.
Signature of Director Signature of Witness
Name of Director (please print) Name of Witness (please print)
Date
APR 2021
6
2021-37
PART D
Undertaking
TO BE EXECUTED BY EACH NEW SHAREHOLDER ONLY
Each new Shareholder of the Health Profession Corporation is required to execute this Undertaking.
I,
Name of Shareholder
, a member of College of Nurses of Ontario
(“College”) and a shareholder of
Name of Corporation (“Corporation”)
UNDERTAKE TO
THE COLLEGE AS FOLLOWS:
1.
I accept professional responsibility for any act or omission of the Corporation that would be professional misconduct
if such act or omission had been committed or omitted by a member of the College.
2. I will ensure that the Professional Corporation does not do or omit to do anything that would be professional
misconduct if done or omitted to be done by me.
3. I will ensure that the College is notified within ten (10) days if I cease to be a shareholder of the Corporation.
4. I acknowledge that a breach of this Undertaking may result in referral of specified allegations of professional
misconduct against me to the Discipline Committee arising out of my failure to abide by any of the terms of this
Undertaking.
5. I acknowledge having been advised to obtain independent legal advice prior to signing this Undertaking.
Signature of Shareholder Signature of Witness
Name of Shareholder (please print) Name of Witness (please print)
Date
2021-37
2021 APR
7