Staple 1 passport

acceptable photo Application for FOR OFFICE USE:

here PEBC ID#:
IMPORTANT: the
date the photo was
Pharmacist
taken must be
stamped or written Document Please complete the checklist on the next
on the back of the page and submit it with this application.
photo Evaluation
Mail to: The Pharmacy Examining Board of Canada, 717 Church Street, Toronto, ON, M4W 2M4.

Personal information Academic Record

Salutation Ms. Include academic year and degree expected/received:

Surname / Family Name

University Dates From/To Degree(s)
MISENA
06/2002 / BS INDUSTRIAL
First Name / Given Names University of the Philippines
04/2007 PHARMACY
CINDY ROSE
/
Former Surname (if applicable, e.g. name before marriage / maiden name)

Mailing Address Licensing Record

Date
#74 2ND STREET, MAKINA
Country Licensing Body Licensed
City Province (mm/yyyy)
PROFESSIONAL
NAIC CAVITE Philippines 02/2008
REGULATION COMMISSION
Country Postal Code
Philippines 4110
Telephone # Cell # (if applicable) Fax # (if applicable)
6346-412-8380 639336635155 Method of payment Visa
Amount paid $530.00
E-mail Date of Birth (dd/mm/yyyy)
Date of payment Jan 31, 2014
cindyrosemisena@yahoo.com 03/08/1985

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)

Signature of Notary Public or Commissioner for Oaths or lawyer or Canadian

Embassy FOR OFFICE USE:

Approved
Checked
 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. If
any item is incomplete or inaccurate on your printed application, please correct it manually using
a pen, directly on the form. You will need to sign this checklist and submit it with your application.

APPLICATION FORM
Name entered exactly as it appears on identification
All other information requested has been accurately 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

I confirm that all of the above requirements have been met.

Applicant name _______________________ Applicant signature________________________

(Please print)