Application for

Pharmacist
Document
Evaluation
FOR OFFI CE USE:
PEBC I DENTI FI CATI ON ________________
Please complete the checklist on the next
page and submit it with this application.

Mail to: The Pharmacy Examining Board of Canada, 717 Church Street, Toronto, ON, M4W 2M4.
All information must be clearly printed or typewritten (other than signatures).


Personal Information Academic Record
Salutation Ms. Miss Mrs. Mr.

Include academic year and degree expected/received:
Surname / Family Name Country, University and
Faculty
Dates From/To
(mm/yy-mm/yy)
Degree(s)

First Name / Given Names

Former Surname (if applicable, e.g. name before marriage / maiden name)

Mailing Address

City Province

Country Postal Code Licensing Record

Country Licensing Body
Date Licensed
(mm/yyyy) Telephone #
( )
Cell # (if applicable)
( )
Fax # (if applicable)
( )


Email Date of Birth (dd/mm/yyyy)



DECLARATION
I hereby declare that all the information given in this application and in all documents
submitted herewith is true and accurate and that the attached photograph is a recent
photograph of myself (within one year). I also declare that I am the person referred to
in the documents which are being submitted in support of this application.
I understand that falsification of this application, submission of falsified documents to
The Pharmacy Examining Board of Canada, (hereinafter referred to as the Board), or
submission of falsified Board documents to other agencies may be sufficient cause for
the Board to bar me from the Evaluating Examination or to take appropriate action as it
sees fit.
I will conduct myself in a professional manner when interacting with the Board and
examination staff before, during and after the examination.
I declare I am not now, nor ever have been, suspended by my pharmaceutical
association, nor have I ever been convicted of any breach of any pharmacy act or
regulations or of any of the acts governing the practice of pharmacy. I also understand
that the accompanying fee cannot be refunded, except under special circumstances
defined by the Board.
I hereby authorize the Board to divulge any information contained in this application,
or information flowing from the results of my document evaluation and examination, to
any Canadian federal, provincial (including regulatory authorities) or educational
authority who, in the opinion of the Board, has legitimate interest in such information.
I make this solemn declaration conscientiously believing it to be true and knowing
that it is of the same force and effect as if made under oath.














Signature of Applicant

Signed before me at (city and date)
FOR OFFICE USE:
Signature of Notary Public or Commissioner for Oaths or lawyer or Canadian Embassy
Fee Paid:

Date Paid: Initials:
DOC1111
1

Glue one passport-
acceptable
photo here
(identical to the photo
in the top left hand
corner).

Staple 1 passport
acceptable photo
here
IMPORTANT: date
photo was taken
must be stamped or
written on the back
of the photo
2

Seal, stamp or
signature of
witness
must cover a
portion of the
bottom of the
front of the
photo and the
application.
PHARMACIST DOCUMENT EVALUATION APPLICATION CHECKLIST
Use this list to check off each item box to show that the item is complete on your application. This will
help prevent the need for documents to be resubmitted if they are not submitted correctly. You will
need to sign this checklist and submit it with your application.
APPLICATION FORM
Name entered exactly as it appears on official identification
All other information requested has been filled in
One photo stapled to the top, left corner with date taken on back
One photo pasted in box in bottom, right corner
Your signature has been added in the space provided in the presence of your witness
Your witness has filled in city, date, their name and their signature
Your witness has signed or stamped the front of the photo on the bottom, right corner
IDENTIFICATION DOCUMENTS
A properly witnessed copy of a primary form of identification with an original, official translation attached
if necessary (Birth Certificate OR both sides of Canadian Citizenship Card) OR a statutory declaration
with support documents
ONLY IF NECESSARY: A properly witnessed copy of any required change of name documents
UNIVERSITY DEGREE CERTIFICATE
A properly witnessed copy of your original language university degree certificate
ONLY IF NECESSARY: An attached official translation of your university degree certificate in English
or French

UNIVERSITY TRANSCRIPTS
You have requested your transcript be sent directly from your university to PEBC
ONLY IF NECESSARY: You have also sent us your original language transcript with an attached
official translation in English or French

LICENSING STATEMENT
You have requested your licensing statement(s) be sent to PEBC directly from any licensing authorities
you are currently licensed by OR have been previously licensed by
ONLY IF NECESSARY: You have also sent us your original language licensing statement with an
attached official translation in English or French
OR
You have sent us a properly witnessed statutory declaration only if you are not currently licensed
anywhere in the world

FEE
A currently dated & signed Canadian certified cheque, money order or bank draft for $530 in Canadian
funds

I confirm that all of the above requirements have been met.
Applicant name _______________________ Applicant signature____________________________
(Please print)