In order for your name and titles to correctly appear on your certificates, please fill out the form below carefully:

Note: Please provide us your legal name and title which you would like to appear on your CBAM certificate(s).
Name*
First Middle Last
Email*
Please type here your exact name with the title combination you wish to appear on your certificate(s). (The capitalization of the titles before and after your name will be manually corrected and then added to your records.)*
Examples of combinations:

Dr. John Smith

Dr. John Smith MD

John Smith MD

John Michael Smith MD

John Smith NP

John Smith RN

John Smith RPN
Please upload a document(s) that supports your title or designation:*
Drop files here or

Max. file size: 256 MB.
*
- By submitting this form, I certify all the provided information is true and correct and Canadian Board of Aesthetic Medicine is released from any liability if the above information is not correct.

Verification of Name and Titles for Certificates