Application For Provisional Register Canadian University Students Page 3
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4Application for Provisional Register
Canadian University Students
Guarantor Information and Declaration
Duties of a guarantor
Your guarantor must perform the following tasks free of charge:
1. Certify the information on your application form by completing and signing the Declaration of Guarantor portion of
this form. Completed form must be submitted to ACP with the application package.
2. Write on the back of the photo, "I certify this to be a true likeness of (your name)" and sign and date.
3. Write on the back of any photocopies to be certified, “I certify this to be a true copy of the original document” and
sign and date.
Eligible guarantors
Your guarantor must:
1. be a Canadian citizen residing in Canada and must be accessible to the Alberta College of Pharmacists for
verification. Relatives may act as guarantors if they are a Canadian citizen residing in Canada.
2. have known you personally for at least two years.
3. hold a current Canadian passport
If you do not know an eligible guarantor, as outlined above, all documents must be signed by a commissioner for oaths,
notary public or lawyer. If signed by a commissioner for oaths, notary public or lawyer this form is not required. All
documents must bear appropriate seal or appropriate license/registration number of the commissioner for oaths, notary
public or lawyer.
Declaration of Guarantor
__________________________________
___________________________________
Guarantor’s surname (please print)
Given name(s)
_____________________________
_______________________
______________________
Occupation
Cdn Passport Number
Email address
_____________________________
_______________________
_______________________
Business telephone number
Home telephone number
Cellular number (optional)
Declaration
I declare that I am a Canadian citizen who holds a valid Canadian passport and, to the best of my knowledge and belief,
all of the statements made in this application are true. I have known the applicant personally for at least two years and
have certified on the back of the photo that the image is a true likeness of the applicant. If applicable, I have also certified
on the photocopies of supplementary documentation that, to the best of my knowledge, the photocopy is a true likeness of
the original.
_____________________________
____________________
________________________
Signature of guarantor
Date
Signed at (city and province)
Alberta College of Pharmacists ■1100-8215 112 St. NW. Edmonton, AB T6G 2C8 ■Tel (780)990-0321 or (877)227-3838 ■ Fax (780)990-0328
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