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05 2. 55 GST 53. 60 PAYMENT MUST ACCOMPANY APPLICATION ALL FEES ARE NON-REFUNDABLE Cheque Payable to College of Pharmacists of Manitoba Interac made at the CPhM Office VISA or MasterCard Number / / / GST R107660664 For Office Use Only Certificate Expiration Date Name of Cardholder Signature of Cardholder Payment Y BY S EMP Date Issued By signing this application I understand that it is a confirmation of information as listed on this entire application and confirmation of all of the...
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