This verifies that The Pharmacy Examining Board of Canada has received

documentation from _____________________________________________________

(you must complete this form and include a self-addressed stamped envelope or
a self-addressed envelope and an International Postage Reply coupon)

Name _________________________________________________________________

Address _______________________________________________________________

______________________________________________________________________


On ________________________________ (date) PEBC will complete.

Form #100D

Authorization Statement

I, the undersigned, _____________________________________________________

born on _____________________give mandate to ___________________________

_____________________________________________________________________

and/or _______________________________________________________________

from the organization of ________________________________________________

having their principal place of business at __________________________________

_____________________________________________________________________

Telephone ____________________________ Fax ____________________________

Email_________________________________________________________________

to inquire, follow-up, process and handle my application and to make representations with The Pharmacy Examining Board of Canada regarding Document Evaluation, the Evaluating Examination or the Qualifying Examination. Please send all correspondence to:  ____the address of my agent or  ____my address


Date ______________________________ Signature __________________________

Form #200

Return to Document Evaluation "Documents Required for Evaluation"