Home
IPO No.:
(if you know)
First Name:
 Please enter your name
Last Name:
 Please enter your namePlease enter your name
Primary Address:
 Please enter your address
City:
Province:
Postal Code:
Pharmacy Name:
Pharmacy Address:
Phone #        Cell #    Fax #  
Did you want your     
information sent to:   
   work    or  home  (please choose one)
E-Mail Address:
 Please enter an email address Please correct your email address format
eg: name@email.com
Please complete the following information

Membership Fees (please select the appropriate category)
Full Annual Fee
$50.00 (plus tax)
Select

Personal Malpractice Insurance and Full Annual Fee
$140.00 (plustax)


Select
Student Fee
$25.00 (plus tax)
Select

Payment Method:  
 Please select a Payment Type
 
 
Payment is made online with a credit card using the Pay Pal Payment system, if you would prefer to pay by cheque, please make your cheque payable to "IPO", your total amount will be shown on the next screen

Protecting your privacy
Your privacy is important to us.  Some information you provide to IPO in this application may be considered personal information.  IPO collects uses and shares the information contained in this membership application for the sole purposes of processing your application and delivering IPO services, programs and publications to you.  IPO does not sell or in any other way provide your personal information to third parties not associated with the provision of IPO services, programs or publications.  IPO uses appropriate safeguards to ensure that your personal information remains confidential.  Should you choose not to provide information IPO is requesting in this membership application, you may not receive certain IPO services, programs, or publications. 

Disclosure Statement

The information provided by me on this application is, to the best of my knowledge, accurate and complete.  Any and all member benefits, provided in good faith by IPO, and entered into by me, are at my own risk.  IPO is not liable for any actions resulting from my personal or business decisions.

  Please make a selection. I accept these terms