Pre Registration Application (non-members) Subscription Personal Info - Saskatchewan College of Pharmacy Professionals

Pre Registration Application (non-members) Personal Info

Salutation

First Name *

Last Name *

Usual Name *

Middle Name(s)

Initials (First name initial and Middle name inital only separated by a period) *

Maiden Name

Designation

Gender

Sex at Birth

Pronouns

Birth Date

Languages in which you can provide services

Indigenous identity

Which of the following best describes you?

Personal Address

Address Line 1

Address Line 2

City

Country

Province/State

Postal/Zip

Home Phone

Mobile Phone will be used for two factor authentication in the future. Please make sure to provide a valid Mobile # on which you can receive SMS.

Mobile Phone

Your password must be at least 8 characters long and contain (capital letter, lowercase letter, number and a symbol).

Username *

Password *

Password Confirmation *

Membership Interval:

04/20/2024 - 04/20/2025, Active as of this Date: 04/20/2024