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Pharmacy Manufactuarers

APPLICATION FOR LICENSE OF A MANUFACTURER OR WHOLESALER UNDER SECTION 36 OF THE ACT

 

    

Section 1 - Particulars of Applicant

Date of birth

Section 2 - Contact Information for Applicant

Section 3 – Education

Date Degree or Certificate Conferred:
       
Date Obtained:

Section 4 – Manufacturer or Wholesaler Information

  

Section 5 - Other Licences/Registration(s)


    
Expiration Date:



    
Expiration Date:

Section 6 - Impairment and/or Drug/Alcohol Addition(s)

  
  

Section 7 - Criminal Activity/Disciplinary Action

Failure to disclose criminal history may result in the denial or your application, even if the records have been expunged.

  
  
  
  
If you answer "Yes" to ANY of the questions in Section 7, you must attach a letter of explanation and a CERTIFIED COPY of the court judgment in the case for EACH incident. If charges were dismissed, provide a letter from the appropriate agency confirming dismissal of the charges.

PLEASE ANSWER THE FOLLOWING QUESTIONS: YES NO

  
  
  
  
  

Section 7 – Upload any relevent attachments

Upload certificate or identity attachments:

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