_________________________________________________________________________________ | | | (Seal of the Order) | | | | THE ORDRE DES PHARMACIENS DU QUÉBEC | | | | Remittance of medications and poisons other than controlled substances and | | controlled drugs to an authorized person by a pharmacist permanently closing | | his pharmacy | | | | I, the undersigned, Mr, Ms .................................................... | | (name) (given name) | | | | ............................................ domiciled at ..................... | | (profession) (address) | | | | ............................................................................... | | (street) (municipality) (telephone) | | | | and practising my profession at................................................ | | (address) (street) | | | | ............................................. or (in the case of a wholesaler, | | (municipality) (telephone) | | | | a hospital, etc.), Mr, Ms ..................................................... | | (name) (given name) | | | | ...................................................................employee of | | (function within the institution concerned) | | | | ................................................................... located at | | (name of institution) | | | | ............................................................................... | | (address) (street) (municipality) (telephone) | | | | hereby declare that I have concluded an agreement with Mr, Ms ................. | | | | ............................................................................... | | (name) (given name) | | | | pharmacist, practising his (her) profession at ................................ | | | | ............................................................................... | | (address) (street) (municipality) (telephone) | | | | on .................................................., in order to acquire all | | (day) (month) (year) | | | | or part (indicate the percentage.....%) of the medications and poisons, other | | than controlled substances and controlled drugs, in his (her) possession on the | | date fixed for the permanent closing of his (her) pharmacy. | | | | And I declare that I am a person authorized under the Act to possess and sell | | the said medications and poisons. | | | | | | | | | | | | ................................... | | signature of the acquirer | | | | Date: .................20...... | |_________________________________________________________________________________|