2021-22 Pharmacy Membership

Renewal Deadline: March 31, 2021

CONTACT INFORMATION
Pharmacy Name*
Contact Person*
First Last
Phone
Address*
Address City Province Postal Code
Preferred Contact Email*
I want to receive member updates, event notifications and other important information via my preferred contact email.*
- Yes
- No
Important Notice
Please be advised that PANL uses email as the primary method of contacting members. You will not receive renewal notices and other important information.
Privacy Statement
Your privacy is important to us. PANL does not sell or otherwise provide your personal information to third parties not associated with the provision of PANL services, programs or publications. PANL uses appropriate safeguards to ensure that your personal information remains confidential. I the undersigned, certify that the information contained in this application is complete and correct and authorize PANL to collect, use and share the information contained in this application for the sole purposes set out in the privacy statement noted above.
Signature*
Date*
Payment of Membership Fee | Online Payment
HST #86818 5208 RT0001
Pharmacy Membership - $445 + hst
Price:
Please note that this form is used for Pharmacy Membership. If you have any questions, please contact PANL Office at 709-753-7881 prior to submitting. If there is an error in selecting the appropriate form and a refund is required, there will be a $15.00 administration fee applied automatically.
Request Invoice - Corporate Payments Only*
An invoice will only be issued if your membership fee is being paid by a corporate office or pharmacy and they require it. If that is not the case please pay by credit card below.
- Send Invoice
- Pay Now by Credit Card
Subtotal
$ 0.00 CAD
HST
$ 0.00 CAD
Total
$ 0.00 CAD
Credit Card*
Card Details
Cardholder Name
To help us match your online payment with your registration form please tell us the legal name on the credit card account used for payment.**
Name
This field is for validation purposes and should be left unchanged.

Telephone:

(709) 753-7881

Toll Free:

(866) 753-7881

Fax:

(709) 753-8882

Email:

email@panl.net

2021-22 Pharmacy Membership

CONTACT INFORMATION

Important Notice

Privacy Statement

Payment of Membership Fee | Online Payment

PANL

Membership