Documente Academic
Documente Profesional
Documente Cultură
acceptable photo
here
IMPORTANT: date
photo was taken
must be stamped or
written on the back
of the photo
Application for
Pharmacist
Document
Evaluation
Mail to: The Pharmacy Examining Board of Canada, 717 Church Street, Toronto, ON, M4W 2M4.
All information must be clearly printed or typewritten (other than signatures).
Personal Information
Salutation
Ms.
Miss
Mrs.
Academic Record
Mr.
Dates From/To
(mm/yy-mm/yy)
Degree(s)
Province
Country
Postal Code
Telephone #
(
)
Email
Licensing Record
Country
Licensing Body
Date Licensed
(mm/yyyy)
DECLARATION
I hereby declare that all the information given in this application and in all documents
submitted herewith is true and accurate and that the attached photograph is a recent
photograph of myself (within one year). I also declare that I am the person referred to
in the documents which are being submitted in support of this application.
I understand that falsification of this application, submission of falsified documents to
The Pharmacy Examining Board of Canada, (hereinafter referred to as the Board), or
submission of falsified Board documents to other agencies may be sufficient cause for
the Board to bar me from the Evaluating Examination or to take appropriate action as it
sees fit.
I will conduct myself in a professional manner when interacting with the Board and
examination staff before, during and after the examination.
I declare I am not now, nor ever have been, suspended by my pharmaceutical
association, nor have I ever been convicted of any breach of any pharmacy act or
regulations or of any of the acts governing the practice of pharmacy. I also understand
that the accompanying fee cannot be refunded, except under special circumstances
defined by the Board.
I hereby authorize the Board to divulge any information contained in this application,
or information flowing from the results of my document evaluation and examination, to
any Canadian federal, provincial (including regulatory authorities) or educational
authority who, in the opinion of the Board, has legitimate interest in such information.
I make this solemn declaration conscientiously believing it to be true and knowing
that it is of the same force and effect as if made under oath.
1
Glue one passportacceptable
photo here
(identical to the photo
in the top left hand
corner).
Seal, stamp or
signature of
witness
must cover a
portion of the
bottom of the
front of the
photo and the
application.
Signature of Applicant
DOC0914
Fee Paid:
Date Paid:
Initials:
IDENTIFICATION DOCUMENTS
A properly witnessed copy of a primary form of identification with an original, official translation attached
if necessary (Passport OR Birth Certificate OR both sides of Canadian Citizenship Card) OR a statutory
declaration with support documents
ONLY IF NECESSARY: A properly witnessed copy of any required change of name documents
UNIVERSITY TRANSCRIPTS
You have requested your transcript be sent directly from your university to PEBC
ONLY IF NECESSARY: You have also sent us your original language transcript with an attached
official translation in English or French
LICENSING STATEMENT
You have requested your licensing statement(s) be sent to PEBC directly from any licensing authorities
you are currently licensed by OR have been previously licensed by
ONLY IF NECESSARY: You have also sent us your original language licensing statement with an
attached official translation in English or French
OR
You have sent us a properly witnessed statutory declaration only if you are not currently licensed
anywhere in the world
FEE
A currently dated & signed Canadian certified cheque, money order or bank draft for $550 in Canadian
funds