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Application for Certificate of Authorization - OCPInfo.com

71 May/2010 Application for a Certificate of Authorization for a Health Profession Corporation The mission of the Ontario College of pharmacists is to regulate the practice of pharmacy, through the participationof the public and the profession, in accordance with standards of practice which ensure that pharmacists provide the public with quality pharmaceutical service and and ChecklistApplication forms for a Certificate of Authorization for a Health Profession Corporation ( Corporation ) that are incomplete will be are reminded that the $ (plus HST) fee accompanying the Application form is fee may be paid by certified, cheque, money order or by cash. (Please note that cash is not recommended)INSTRUCTIONSP rior to submitting your Application form, pleaseensure that the following criteria have been met: A Director (must be a member of the College) authorizedto sign on behalf of the Corporation has signed theApplication for a Certificate of Authorization Form A.

7 May/2010 1 Application for a Certificate of Authorization for a Health Profession Corporation The mission of the Ontario College of Pharmacists is to regulate the …

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Transcription of Application for Certificate of Authorization - OCPInfo.com

1 71 May/2010 Application for a Certificate of Authorization for a Health Profession Corporation The mission of the Ontario College of pharmacists is to regulate the practice of pharmacy, through the participationof the public and the profession, in accordance with standards of practice which ensure that pharmacists provide the public with quality pharmaceutical service and and ChecklistApplication forms for a Certificate of Authorization for a Health Profession Corporation ( Corporation ) that are incomplete will be are reminded that the $ (plus HST) fee accompanying the Application form is fee may be paid by certified, cheque, money order or by cash. (Please note that cash is not recommended)INSTRUCTIONSP rior to submitting your Application form, pleaseensure that the following criteria have been met: A Director (must be a member of the College) authorizedto sign on behalf of the Corporation has signed theApplication for a Certificate of Authorization Form A.

2 The same Director who signed Form A, must also signthe required Statutory Declaration Form B Each Director (must be a member of the College) of theCorporation has executed an Undertaking in Form C. Each Shareholder (must be a member of the College) ofthe Corporation has executed an Undertaking in FormD, excluding Director(s) who have completed Form C. Should any amendments or changes occur to theCorporation before the submission of Application to theCollege, a certified copy of the amending Certificate (s)issued by the Ministry of Government Services must beprovided with the Application .(See Checklist #6) In completing the Application Form, if more space wasrequired, ensure that you have attached additionalpages appropriately labeled. Should you require morecopies for Form C and Form D, please make as manycopies of the form as The Application for a Certificate of Authorization for a HealthProfession Corporation is considered incomplete without thefollowing A Application for a Certificate of Authorization issigned and completed by the same Director of theCorporation who signed the Statutory Declaration (SeeChecklist #3.)

3 In the amount of $ (plus HST) payable tothe Ontario College of B Statutory Declaration has been executed by aDirector of the Corporation before a commissioner ornotary public not more than 15 days before theapplication is submitted to the Certificate of Status of the Corporation issuedby the Ministry of GovernmentServices not more than30 days before the Application is submitted to theRegistrar which indicates that the corporation is copy of the Certificate of Incorporation of theCorporation (must be issued by the Ministry ofGovernment Services.) copy of every Certificate of the Corporation(must be issued by the Ministry of Government Services)that has been endorsed under the Business CorporationsAct (Ontario) as of the day the Application is C Director Undertaking is to be completed byeach Director of the D- Shareholder Undertaking is be completed byeach shareholder of the Corporation, excludingDirector(s) who have completed Form C.

4 NAME OF HEALTH PROFESSION CORPORATIONONTARIO CORPORATION No.(issued by the Ministry):Note: The name of the Corporation must comply with the requirements of s. 1 of Ontario Regulation 39/02 of the Regulated Health Professions Act, 1991 (Ontario). BUSINESS ADDRESS OF HEALTH PROFESSION CORPORATIONA ddress:Suite:City:Province:Postal Code:Tel: ( )Fax: ( )Email (optional):NAME(S) OF DIRECTOR(S)/SHAREHOLDER(S) AS OF THE DAY THE Application IS SUBMITTED (must be a member of the College) AND HIS/HER PRACTICE ADDRESS, PRACTICE TELEPHONE NUMBER AND REGISTRATION NUMBER WITH THE COLLEGE AS OF THE DAY OF Registration #:Last Name:Given:Middle Name(s):Business Address:Suite:City:Province:Postal Code:Tel: ( )Fax: ( )Email (optional):OCP Registration #:Last Name:Given:Middle Name(s):Business Address:Suite:City:Province:Postal Code:Tel: ( )Fax: ( )Email (optional).

5 (Attach additional pages appropriately labeled, if necessary)FORM AApplication for a Certificate of Authorization for a Health Profession Corporation May/201072 AThe mission of the Ontario College of pharmacists is to regulate the practice of pharmacy, through the participationof the public and the profession, in accordance with standards of practice which ensure that pharmacists provide the public with quality pharmaceutical service and No.:Date Issued:Date Denied:Date Received:FOROFFICEUSE ONLY73 FORM A - Page 2 Application for a Certificate of Authorization for a Health Profession Corporation May/2010 THE CORPORATION INTENDS TO PRACTISE AND/OR CARRY ON BUSINESS IN THE FOLLOWING LOCATION(S):Address:Suite:City:Province: Postal Code:Tel: ( )Fax: ( )Email (optional):Address:Suite:City:Province:P ostal Code:Tel: ( )Fax: ( )Email (optional):Address:Suite:City:Province:P ostal Code:Tel: ( )Fax: ( )Email (optional):NAME(S) OF DIRECTOR(S)/OFFICER(S) AS OF THE DAY THE Application WAS SUBMITTED (must be a member of the College)NOTE: All director(s) and officer(s) must also be shareholders of the corporation.

6 Please check ( ) the appropriate box . If youare an officer, please indicate the title of your office, example: President, Secretary, Treasurer, etc).OCPR egistration No.:Full Name:Director: Officer:Officer Type:NAME(S) OF INDIVIDUAL(S) (must be a member of the College) THAT WILL PRACTISE ON BEHALF OF THECORPORATION INCLUDING ALL SHAREHOLDERS AND PHARMACIST EMPLOYEES OF THE CORPORATIONAS OF THE DAY THE Application WAS No.:Full A74 FORM A - Page 3 Application for a Certificate of Authorization for a Health Profession Corporation May/2010 PLEASE PROVIDE A BRIEF DESCRIPTION OF THE PROFESSIONAL ACTIVITIES TO BE CARRIED OUT BY THE CORPORATION. NOTE:The Corporation cannot carry on and cannot plan to carry on, any business that is not the practice of pharmacy or activitesrelated or ancillary to the practice of pharmacy (Regulation 39/02, subparagraph 6(ii) of subsection 2(1) confirm that the information contained in this Application for a Certificate ofAuthorization for a Health Profession Corporation is complete and of Director Authorized to sign on behalf of the CorporationPlease print name clearlyCollege Registration , , a director of , (Name of Director)(Name of Health Profession Corporation)do hereby solemnly certify that the following statements are am a member of the College holding Certificate of Registration am a director of the Corporation and have the authority to apply for a Certificate of Corporation is in compliance with section of the Business Corporations Act (Ontario)

7 As of thedate this Statutory Declaration is Corporation does not plan to carry on and will not carry on any business that is not the practice ofpharmacy or an activity related or ancillary to the practice of that has been no change in the status of the Corporation since the date of the Certificate of statusenclosed with the Application for a Certificate of Authorization that accompanies this Statutory information contained in the Application for a Certificate of Authorization that accompanies thisStatutory Declaration is complete and accurate as of the day this Statutory Declaration is B - STATUTORY DECLARATIONA pplication for a Certificate of Authorization for a Health Profession Corporation May/2010 The mission of the Ontario College of pharmacists is to regulate the practice of pharmacy, through the participationof the public and the profession, in accordance with standards of practice which ensure that pharmacists provide the public with quality pharmaceutical service and before me in the City ofin theofthisday of , Commissioner, etc.

8 (Signature of Declarant)1 Section of the Business Corporations Act (Ontario), reads as follows: Application of (1) This Act and the regulations apply with respect to a professionalcorporation except as otherwise set out in this section and , and and the regulations. 2000, c. 42, Sched., s. for professional corporations(2) Despite any other provision of this Act, a professional corporation shallsatisfy all of the following conditions:1. All of the issued and outstanding shares of the corporation shall belegally and beneficially owned, directly or indirectly, by one or moremembers of the same All officers and directors of the corporation shall be shareholders ofthe The name of the corporation shall include the words ProfessionalCorporation or Soci t professionnelle and shall comply with therules respecting the names of professional corporations set out inthe regulations and with the rules respecting names set out in theregulations or by-laws made under the Act governing the The corporation shall not have a number The articles of incorporation of a professional corporation shallprovide that the corporation may not carry on a business other thanthe practice of the profession but this paragraph shall not beconstrued to prevent the corporation from carrying on activitiesrelated to or ancillary to the practice of the profession, including thetemporary investment of surplus funds earned by the , c.

9 42, Sched., s. acts not invalid(3) No act done by or on behalf of a professional corporation is invalidmerely because it contravenes this Act. 2000, c. 42, Sched., s. agreements void(4) An agreement or proxy that vests in a person other than a shareholderof a professional corporation the right to vote the rights attached to ashare of the corporation is void. 2000, c. 42, Sched., s. shareholder agreements void(5) A unanimous shareholder agreement in respect of a professionalcorporation is void unless each shareholder of the corporation is amember of the professional corporation, 2000, c. 42, Sched., s. C - DIRECTOR UNDERTAKINGA pplication for a Certificate of Authorization for a Health Profession Corporation May/2010 The mission of the Ontario College of pharmacists is to regulate the practice of pharmacy, through the participationof the public and the profession, in accordance with standards of practice which ensure that pharmacists provide the public with quality pharmaceutical service and Director of the Health Profession Corporation to execute a separate UndertakingI, , a member of the Ontario College of pharmacists ( College ),(Name of Director)a director and a shareholder of (Name of Health Profession Corporation)UNDERTAKE TO THE COLLEGE AS FOLLOWS:1.

10 I accept professional responsibility for any act or omission of the Corporation that would be professional misconduct if suchact or omission had been committed or omitted by a member of the will ensure that the Corporation does not do or cause to be done or omit or cause to be omitted anything that would beprofessional misconduct if done or omitted to be done by a member of the I will ensure that the Corporation does not engage in the practice of pharmacy or any activity related or ancillary to thepractice of that profession unless it maintains a valid Certificate of Authorization issued by the I will ensure that the Corporation does not practice under any name other than the name of the Corporation, a practicename previously approved by the College for use by a shareholder of the Corporation or a name permitted by I will ensure that the Corporation complies with the Regulation Health Professions Act, 1991, the Pharmacy Act, 1991, andThe Drug and Pharmacy Regulated Act, the regulations made under those Acts, and the by-laws of the will ensure that the College is notified immediately of any change in shareholders of the Corporation and that any futureshareholder of the Corporation execute and file with the College, within ten days of becoming a shareholder of theCorporation.


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