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

      DATE OF BIRTH

EMPLOYMENT

BANKING INFORMATION

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

      DATE OF AUTHORIZATION (DATE THIS FORM WAS FILLED)
ONLY THOSE SIGNING MAY CHARGE TO THIS ACCOUNT. WE WILL CONTACT YOU AFTER PROCESSING.
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