APPLICATION FOR NEW TELEPHARMACY LICENCE …

1 College of Pharmacists of British Columbia | 200 - 1765 W est 8th Ave Vancouver, BC, V6J 5C6 | Tel: | Fax: | 9040-App_New_Pcy_Telepharmacy Effective 2017-11-15 (Posted 2017-11-14) APPLICATION FOR NEW TELEPHARMACY LICENCE Community Fo rm 2 Page 1 of 3 1. TELEPHARMACY INFORMATION Proposed Operating Name Proposed Opening Date MMM | DD | YYYY TELEPHARMACY Address City Province BC Postal Code Mailing Address (if different from above) City Province Postal Code Email Address Phone Number Fax Number Website Software Vendor (for dispensing) Pharmacy Technician Name Registration Number (BC)

2 OWNER S INFORMATION Name of Company on Notice of Articles/BC Company Summary BC Incorporation Number NEXT CLOSEST COMMUNITY PHARMACY/ TELEPHARMACY Pharmacy Name City Approximate Distance from Proposed TELEPHARMACY Location (KM): 2. CENTRAL PHARMACY INFORMATION Operating Name PharmaCare Code Pharmacy Address City Province BC Postal Code Email Address Phone Number Fax Number Manager Name Registration Number (BC) OWNER S INFORMATION Name of Company on Notice of Articles/BC Company Summary BC Incorporation Number 3. PRIMARY CONTACT PERSON Name Position/Title Email Address Phone Number Fax Number College of Pharmacists of British Columbia | 200 - 1765 W est 8th Ave Vancouver, BC, V6J 5C6 | Tel: | Fax: | 9040-App_New_Pcy_Telepharmacy Effective 2017-11-15 (Posted 2017-11-14) APPLICATION FOR NEW TELEPHARMACY LICENCE Community Fo rm 2 Page 2 of 3 4.

3 APPLICANT INFORMATION Name of Authorized Representative Position/Title of Authorized Representative Signature Date MMM | DD | YYYY The College collects the personal information on this APPLICATION form to process the APPLICATION and administer the College's related activities. The collection is authorized by the Pharmacy Operations and Drug Scheduling Act, Health Professions Act, and Freedom of Information and Protection of Privacy Act. Should you have any questions about the collection, please contact the College s Privacy Officer at 604-733-2440 or 1- 800-663-1940 or College of Pharmacists of British Columbia | 200 - 1765 W est 8th Ave Vancouver, BC, V6J 5C6 | Tel: | Fax: | 9040-App_New_Pcy_Telepharmacy Effective 2017-11-15 (Posted 2017-11-14) APPLICATION FOR NEW TELEPHARMACY LICENCE Community Fo rm 2 Page 3 of 3 5.

4 PAYMENT INFORMATION TELEPHARMACY (Remote Site) Proposed Operating Name Central Pharmacy Operating Name Method of Payment: Cheque/Money order (payable to College of Pharmacists of BC) VISA MasterCard Card Number Expiry Date (MM/YY) APPLICATION fee Initial LICENCE fee GST Total GST # $ $ $ $ R106953920 Cardholder Name Cardholder Signature For office use ONLY iMIS ID: Finance stamp: Lic initials: Date to Finance.