MOA Students Application Form

Application Form for Pharmacy Assistant Students of Heritage, ABES, and Robertson for CSDM

Please note that Cranston Ridge Medical Clinic and Cranston Smart Drug Mart adopt the same policy for admission to practicums to be completed at their respective sites. Therefore, the application process is the same for both sites and it is processed through the same channel. As a Pharmacy Assistant student, you are required to complete the application form below and upload all the required documents to be admitted to the clinical practicum at CSDM (pharmacy). Please note that having applied does not guarantee you a spot in the practicum. The final decision about your admission is the exclusive prerogative of CSDM for Pharmacy Assistant students. We reserve the right to deny you admission to our practicum program for any reason without having to provide you or your institution with any explanation.

Here are the documents that you need to complete and upload onto the application form below:

WHMIS certification
Confidentiality Contract
Immunization Record that your MD or NP completed for you.

First Name of Applicant

Last Name of Applicant

Date of Birth of Applicant

Year

Month

Day

Email of Applicant

Cell # of Applicant

What term are you applying for?

Alternative Term (should the other one not be available)

Start Date of Intended Practicum

End Date of Intended Practicum

Status in Alberta

Canadian citizen

Permanent resident of Canada

Student visa holder

Name of Institution You Attend

Passport Biodata Page

PR Card of Student or Student Permit (Canadians upload passport biodata page again)

Alberta Driver's License OR Alberta ID Card

Immunization Record (link found above)

Signed Confidentiality Contract (link found above)

WHMIS Certificate (link found above)

Up-to-date CV

The collection of this information is compliant with the Personal Information Protection Act of the province of Alberta.

By submitting this application and documents, I agree to the terms and conditions of CRMC/CSDM regarding the management of my personal data including the right for CRMC/CSDM to hand this information over to the police on their request.

Date of Application

Year

Month

Day

Signature of Applicant

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

You may use your mouse to sign inside the box, or you may choose to upload your signature as a file, or you may choose to type your signature. All three forms are legally accepted in Alberta.