Pharmacy Technician Society of Alberta (PTSA) -

The 20th Annual Alberta Pharmacy Technician Conference - Rising to the Challenge - September 17 - 19, 2010 - Click here to register

Last Name

First Name

Salutation

Mr Ms Mrs

Date of Birth

Home Address
Street
City/Town:
Province:
Postal Code:

Work Address
Business Name
Street
City/Town:
Province:
Postal Code:

Home Telephone

780	123	4567	Extension (optional)

Work Telephone

780	123	4567	Extension (optional)

Email Address (work or home)

Job Title

Please make this my primary address: Home Work

Other Information (optional)

Are you a graduate of a formal Pharmacy Technician program?
Yes No

Name of School:

Grad Year:

Have you received any of the following certifications?

PTeB (formerly PTCB-AB) OCP PTCB-US None

What is your practice setting?

Hospital	Community	Long-term Care
Education	Administration	Other (please specify)

Membership Categories

(Membership valid until June 30, 2009)

Full Member	Pharmacy Technician who resides in Alberta
$60.00 + $3.00 (GST) = $63.00	Voting Member - Eligible to receive publications and benefits

Associate Member	Pharmacy Technician who is not a resident of Alberta (or) Pharmacy industry representative
$45.00 + $2.25 (GST) = $47.25	Non-Voting Member - Eligible to receive publications and benefits

Student Member	Student enrolled in a formal pharmacy technician training program
$37.50 + $1.88 (GST) = $39.38	Non-Voting Member - Eligible to receive publications and benefits

Pharmacy Assistant Member	Individual working in a support capacity in a pharmacy who is not a Pharmacy Technician
$37.50 + $1.88 (GST) = $39.38	Non-Voting Member - Eligible to receive publications and benefits

Privacy-Disclosure

Your privacy is important to us. Some information you provide to PTSA in this application may be considered personal information. PTSA collects, uses and shares the information contained in this membership application for the sole purposes of processing your application and delivering PTSA services, programs and publications to you. PTSA uses appropriate safeguards to ensure that your personal information remains confidential.

The information provided by me on this application is to the best of my knowledge accurate and complete. By clicking the checkbox below I agree to support the objects of the Society and comply with the Bylaws, policies and Code of Ethics.

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