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SAMPLE ONLY - Do NOT use as application FOR OFFICE USE ONLY: Do not write in

PEBC IDEN TIFICATION #: _____ this space _


Attach one
passport sized
Application for
photograph here,
with date taken
s t am p e d o n th e b a ck. Document Evaluation
Mail to:

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The Pharmacy Examining Board of Canada, 4 15 Yonge Street, Suite 601, Toronto, O ntario M 5B 2E7
All information must be clearly printed or typewritten.
________________________________________ ___________________________________________________
Surname: 9 Ms. 9 Miss 9T Mrs. Family name as on
Birth Certificate Academic Record
Mehta (or Marriage Certificate) Include academic year and degree expected/ received:
________________________________________________________
Given N ames: Faculty and University Dates From/ To Degree(s)
Given name as on
Nena Birth C ertificate
________________________________________________________

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Banga lore University Sept ‘90 / June ‘96 Bach. of Pharm.
Former Surname (if applicable, e.g. maiden name):
Patel University you
Name before Dates you attended Degree obtained
_________________________________________ marriage attended Un iversity
Street Address:
4 Tanka Road Licensing Record:
________________________________________________________
City: Province:
Bangalore Karnataka Country Licensing Body Date Licensed
________________________________________________________
In dia Ba ng alo re P ha rm Co unc il September 1996
Country: Postal Code:
India 560 000

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________________________________________________________ Country where you Name of Licensing
Area Code & Telephone N umber: were m ost re cen tly Au thority
licensed
91-080-1234-567
________________________________________________________ Date of expected entry into Canada:
Area Code & Fax Number: September 2006
91-080-1234-567 _______________________________________________
__________________________________________
Email: If possible, please Province of expected residence:
nenamehta@email.com supply Email Address On tar io
________________________________________________________ _______________________________________________
Date of Birth (day / month / year):

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1 January 1970
________________________________________________________

Declaration Glue one


Glue one pa sspo rt size
photograph
I hereby declare that all the information given in this application and in all documents here photograph here.
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 Staple one additional
in the documents which are being submitted in support of this application. iden tical ph otog raph to
I understand that falsification of this application, submission of falsified documents the top left hand corner of

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the application.
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 W itness
for the Board to bar me from the Evaluating Examination or to take appropriate action
as it sees fit.
Ajay Abdel Kumar places official
s ea l o r s ta m p
here
I declare I am not now, nor ever have been, suspended by myNu pharmaceutical
m ber o f years
association, nor have I ever been convicted of any breach of any pharmacy practising asact
a or Sea l, stam p or sig natu re
regulations or of any of the acts governing the practice of pharmacy. pharmacist
I have been of nota ry public ,
engaged in the practise of pharmacy for _________ 9 years. com m ission er for oa ths,
I also understand that the accompanying fee cannot be refunded, except under lawyer or the Canadian
special circumstances defined by the Board. Embassy must cover a
portion of the photograph.
I hereby authorize the Board to divulge any information contained in this application W itness

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to any authority who, in the opinion of the Board, has a legitimate interest in such signs in both
information. places
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.
Nena Mehta Sign name
FOR OFFICE USE ONLY
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in presence _______________________________________
Signature of Applicant of witness FEE PAID
Bangalore, India 1 March 2006 ____________________________ Do not write in
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DATE PAID this space
Declared before me at ( city and date) _______________________________________
Ajay Abdel Kumar Notary Public CR
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Signature of N otary Public, Commissioner for O aths, Lawyer or Canadian Em bassy