2024 CLEARANCE FORM – RETURNING REGISTRATION

FILL OUT THE CLEARANCE FORM BELOW

Zone*
PCN Registration Number*
Full Name*
Street Address 1
Street Address 2
Postcode / Zip
Phone Number (Office)*
Phone Number (Whatsapp)
Email*
Physical school attended with year of graduation*
Any other qualification
Pharmaceutical premises information – State the name and address of premises you practiced in 2023*
State the name and address of premises where you would practice in 2024*
Are you the pharmacist director? If yes, state the % of equity you own in the company
Do you have the original pharmacy emblem? If yes, state the pharmacy emblem number
Pharmacist & premises licenses and form CAC 2 & 7 showing number of shares held by the director – optional
Additional documents 1
Additional documents 2
If the information given above is correct and you understand that if at any time such information is found to be untrue, a disciplinary action will be taken against you as the association may deem appropriate. Type YES to confirm*
Upload Proof of Payment: N20,410 to Zenith Bank, 1011986062, Association of Community Pharmacists of Nigeria*
Zonal coordinator’s name*

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Association of Community Pharmacists of Nigeria, Eti Osa. Empowering pharmacists, protecting the people.

2024 CLEARANCE FORM – RETURNING REGISTRATION

FILL OUT THE CLEARANCE FORM BELOW

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