Hospital & Not-for-Profit Supporters Application

July 1, 2024 - June 30, 2025
Profile Information
Organization*

NameWebsite
Address*

Street Address 1

Street Address 2

CityProvince/State

Postal / Zip CodeCountry
Account Administrator
This individual will be the contact for your membership. They will receive access to member content on CSHP.ca and subscriptions to Interactions, Avenues for Education, and CSHP e-Newsbrief newsletters.
Name*
Job Title/Position
Email*
Phone Number*

Area CodePhone Number
Please send CSHP newsletters to this email inbox.*

YesNo
Please send me information about purchasing Hospital Pharmacy 101 modules for my organization.*

YesNo
Fees
Select your Type and Category:*
* A hospital site is counted if pharmacy staff regularly attend the site; sites fully staffed remotely are not included.
For multi-site categories, list the hospitals/health centres that are part of your organization:
Payment Information
Invoicing Information: *

Name and Job Title/Position

Street Address

CityState / Province

Postal / Zip CodeCountry
You will receive logo recognition on CSHP.ca. Please upload a high-resolution logo here: *

Browse Files

Cancelof
Special Instructions:
Please note: prices will be subject to the applicable GST/HST: 5% AB, BC, MB, NT, NU, QC, SK, YT; 13% ON; 15% NB, NL, NS, PE (#R10686690).
If your organization is GST/HST exempt, provide your exemption number here:
Authorizing Name*
Signature
Please verify that you are human*
Should be Empty:

July 1, 2024 - June 30, 2025