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Get Permission Request Form - Canadian Pharmacists Association

1785 Alta Vista Drive, Ottawa, ON K1G 3Y6 Tel.: 613-523-7877 or 1-800-917-9489 Request Number: (CPhA use only) 1. Applicant Information Complete Name: Title (Mr., Mrs., Ms., Dr.), First and Last Name Organization (if applicable) Are you a member of CPhA? Yes Member # No Nature of Organization (e.g. Educational Institution, Nonprofit Association, Commercial Company, Library, N/A) Mailing Address City/Town Province/State Telephone No. (include area code) Postal/Zip Code Co.

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