PHARMACIST DOCUMENT PEBC ID #

if previously assigned

EVALUATION APPLICATION NAPRA GATEWAY ID #

PERSONAL INFORMATION
Surname(s)/Family Name(s)

First Name & Middle Name(s) as they appear on your documents

Former Name(s) prior to marriage or other legal name changes Date of Birth dd/mm/yyyy

Email

CANDIDATE DECLARATION CANDIDATE PHOTO

I, the undersigned, hereby declare that the information

given in this application is true and accurate and that the Photo must be taken within one year of PEBC receiving this application

attached photograph of me was taken within twelve

months of the date of submission of this document. I Maximum size: 50 mm x 70 mm Witness stamp/signature
must cover both front of
acknowledge that this document will expire five years photo and application
following the date of its acceptance by PEBC. Glue one passport
acceptable photo here Example

Minimum size:
35 mm x 45 mm
Signature

A seal or stamp must be in

English or French

X
Candidate Signature

WITNESS DECLARATION FOR OFFICE USE ONLY

Processed
I certify that the individual named on this form did appear before me. I identified this individual by
comparing their physical appearance with the photograph on their valid government-issued identifying
document(s) and with the photo attached to this document. The statements in this document are sworn
before me by the individual in: Approved

City On dd/mm/yyyy

Signature of Witness

Witness name please print

Witness Title/Profession

Send to: PEBC, 717 Church St. Toronto, ON, M4W 2M4