Membership Application


Personal Information


First Name Name is required.
Last Name Name is required.
Address
Address is required.		 City
City is required.
Province Postal
Home Phone Work Phone
Phone# is required.
Email
Email is required. Invalid format.		 Work Fax

What type of Pharmacist are you:
Where do you work?
What year did you start practicing pharmacy? Must be a valid year
Has a Pharmacist Malpractice claim ever been made against you
and/or the Pharmacy you were affiliated with?

No Yes

Are you aware of any incidents or circumstances which could lead to a Pharmacist Malpractice claim?
No Yes

Membership Detail


I am RENEWING my membership I am JOINING for the first time
Full Year

Active Member $337.45
New Graduate Member $295.80
CSHP Member $337.45
Associate Member $132.75

  Personal Malpractice Limit Premium Rate
$2,000,000 per occurrence and aggregate $0.00
$2,000,000 per occurrence and $4,000,000 aggregate $17.00
$5,000,000 per occurrence and aggregate $79.50

Please note: Active Members, CSHP Members and New Graduate Members receive $2,000,000 Personal Professional Malpractice Insurance through MSP Membership

Communication Newsletter

In an attempt to become more environmentally friendly the MSP is offering an electronic version of the "Communication" newsletter. Please indicate your preference by checking the appropriate box:

I would prefer to receive an electronic version of "Communication" by email.
I would prefer to receive a print version of "Communication" by post.

Donations


$ Invalid format. Donation to Friends of Pharmacy
$ Invalid format. Donation to the MSP Public Relations Committee Fund

Payment Detail


Sub Total $337.45
GST $16.87
Total $354.32

Cheque
Time Payments (contact MSP for details)
Visa
MasterCard

Credit Card# Invalid format.
CVN# ? Invalid format.
Name on Card
Expiry Date / Invalid format.

Yes, I would like my payment held until June 30, 2011

Anti-spam question: A value is required. + 3 = 5

If this is a new application for coverage, the applicant agrees that any such claims, or incidents or circumstances which may lead to a claim, are excluded from this proposed coverage whether or not disclosed.

DECLARATION:
I declare that the above statements and particulars are true and that I have not omitted or suppressed or misstated any material facts. I understand that if no Excess Insurance selection is made above that I have opted for the Basic $2 Million ONLY, which is inclusive with my MSP Membership.

I agree I disagree

BY CLICKING ON THE SUBMIT BUTTON YOU EXPRESSLY ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THE DECLARATION.

Send Cheque to:
Manitoba Society of Pharmacists
202 - 90 Garry St., Winnipeg, MB, R3C 4H1