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PEI Pharmaceutical

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PEI Pharmaceutical Powered By Docstoc
					                                                                         PO Box 24042 , 13 Stratford Rd
                                                                         Stratford, PE Canada C1B 2V5
PEI Pharmacists                                                          Phone / Fax (902) 367-7080
                                                                         E-mail: peipharm@hotmail.com
Association                                                              www.peipharm.info


                                   Registration Form
                        PEI Pharmacists Association Membership
                              April 1, 2008 - March 31, 2009
Name:
Home Address:
Postal Code
Workplace:
E-mail address (please print clearly):

Preference for mailings:       Home       □                Work     □
Dues:PEI Pharmacists Association ($390.00)………………A $ 390.00
        (includes CPBA malpractice insurance $140)

For optional excess coverage, check below:
              CPBA Personal Malpractice Limit                                Premium Rate
                $1 000 000 per occurrence/aggregate                   Included in Membership Fee
          □     $2 000 000 per occurrence/aggregate                                 $51.00
          □     $3 000 000 per occurrence/aggregate                                $141.00
          □     $4 000 000 per occurrence/aggregate                                $177.00
          □     $5 000 000 per occurrence/aggregate                                $210.00

          Optional excess coverage premium rate:................................... B $_______
          TOTAL DUE (A+B):....................................................... $_______
 *Has a Pharmacist malpractice claim ever been made against you and/or the pharmacy
 you have been affiliated with?                                                        □ Yes     □ No
 *Are you aware of any incidents or circumstances which could lead to a claim?         □ Yes     □ No
DECLARATION: I declare that the above statements are true & that I have not omitted or suppressed or
misstated any material facts.
    Signature:_______________________________                 Date:_______________________




                Please make cheques payable to the PEI Pharmacists Association.

				
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