2023-24 Pharmacist/Intern Membership Prorated

Pro-rated Oct 1, 2023 – March 31, 2024

Any pharmacist who is currently licensed and practicing pharmacy in Newfoundland and Labrador. This includes practicing pharmacy interns.

Supporting – Any person that was previously licensed to practice pharmacy in Newfoundland and Labrador, and whose current status is non-practicing (i.e. retired, leave of absence).

CONTACT INFORMATION

Member Name*

First Last

Middle Name or Initial

We have several members with same or similar names.

Member's Address*

Address City Province Postal Code

Practice Site

Practice Site Address

Address City Province Postal Code

Preferred Contact Email*

Telephone*

I want to receive member updates, event notifications and other important information via my preferred contact email.*

Yes

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.

MEMBERSHIP INFORMATION

License Number*

*NOTE: PLEASE ENTER “PENDING” IF WAITING FOR LICENSE NUMBER*

Zone*

See Zone Map to right.

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*

MEMBERSHIP CATEGORIES-Prorated

REGULAR MEMBER | $220 + HST
Any pharmacist who is licensed to practice pharmacy in the province of Newfoundland and Labrador. This includes practicing pharmacy interns.

SUPPORTING MEMBER | $127.50 + HST
Any person that was previously licensed to practice pharmacy in the province of Newfoundland & Labrador, and whose current status is non-practicing (i.e. retired, leave or absence).

HONORARY MEMBER | FREE
Any pharmacist who is a Regular or Supporting Member and has been awarded Honorary Life Membership.

Payment of Membership Fee

Select Desired Membership | Online Payment

Membership fees subject to HST.

Regular Member

Supporting Member

Honorary Member

Select Honorary Status Awarded

Honorary Regular Status

Honorary Supporting Status

Please note that this form is used for Regular Pharmacist 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.

Please note that this form is used for Supporting Pharmacist 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.

Subtotal

$ 0.00 CAD

HST

$ 0.00 CAD

Total

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.

2023-24 Pharmacist/Intern Membership Prorated