First Name:
Last Name:
Social Insurance Number:
( for issuance of T4A form . may provide via phone )
.
Address:
City /Province:
Postal Code:
Telephone
Cell:
Fax:
Email Address:
RX License #:
( please email or fax a copy of your pharmacy license )
Province(s) Licensed in:
Degree:	BSc ( Pharmacy ) Pharm D
Other:
Do you carry Malpractice Insurance ?	Yes No
( please fax or email a copy of proof of Insurance )
What Pharmacy Systems are you familiar with ?	Applied Robotics Tech RX PDX
.	Kroll Zodall Propharm
.	Paley Commander
Other Systems(s)
.
Comments: