This is an application form to apply for the Pharmasave Client Card. The Client Card account is available at the MacQuarries, Kinburn, Wilsons and MacKinnons Pharmasave locations only.

To ensure proper consideration, please fill in the information below as completely and accurately as possible. This is a secure form and all information will be encrypted.

PERSONAL INFORMATION

FIRST NAME *

LAST NAME *

MAILING ADDRESS *

CITY/TOWN

PROVINCE

POSTAL CODE

HOME PHONE # *

WORK OR CELL PHONE #

EXT.

EMAIL ADDRESS *

SOCIAL INSURANCE #

DATE OF BIRTH

MONTH

EMPLOYMENT

EMPLOYER

POSITION

CONTACT

PHONE #

EXT.

BANKING INFORMATION

BANK

ADDRESS

CONTACT

PHONE #

EXT.

PERSONAL REFERENCE

PHONE NUMBER

CREDIT CARD NUMBER

EXPIRY

BANK OF CREDIT CARD

CREDIT CARD NUMBER

EXPIRY

BANK OF CREDIT CARD

PRESCRIPTION DRUG INSURANCE COMPANY

OTHER CHARGE ACCOUNTS

I WILL ASSUME ALL AMOUNTS OWING ON THIS ACCOUNT. I UNDERSTAND TO MAINTAIN MY ACCOUNT IN GOOD STANDING, THE “AMOUNT DUE” IS NET 30 DAYS FROM STATEMENT DATE (THE END OF THE MONTH). INTEREST CHARGES OF 2% PER MONTH (26.82% P.A.) WILL APPLY TO BALANCES OVER 30 DAYS. I AUTHORIZE DELINQUENT ACCOUNT BALANCES TO BE CHARGED TO THE ABOVE CREDIT CARD IN MY NAME OR TO BE SENT FOR COLLECTION AND ACCOUNT CLOSED. I AUTHORIZE A CREDIT CHECK TO BE PERFORMED.

AUTHORIZED USERS FOR CARD

AUTHORIZED TO CHARGE TO ACCOUNT

DATE OF AUTHORIZATION (DATE THIS FORM WAS FILLED)

MONTH

ONLY THOSE SIGNING MAY CHARGE TO THIS ACCOUNT. WE WILL CONTACT YOU AFTER PROCESSING.

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