Pharmacy Technician Injection Training Program

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Pharmacy Technician Registration Number*

I will be paying by*

Money OrderChequeVisa/Mastercard

Subtotal

HST

Amount Owing

Registration Payment*

CADDescription

Credit Card (VISA or Mastercard only, cannot accept AMEX or Visa Debit)
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Payment Process:

Please mail cheques and money orders to:

Attn: Kayla Cousens
School of Pharmacy, Room H3441
Memorial University of Newfoundland
300 Prince Philip Drive, St. John’s, NL A1B 3V6

This information is collected and maintained by the School of Pharmacy to administer the Pharmacy Technician Injection Program as accredited by the Newfoundland Labrador Pharmacy Board and use for no other reason. The information on this form is collected under the authority of the Access to Information and Protection of Privacy Act, 2015 (SNL2015 Chapter A-1.2). Questions about the collection and use of this information may be directed to the Senior Administrative Office, School of Pharmacy at 709-864-7128 or pharminfo@mun.ca.