Collection Location Agreement – MB - Health Products Stewardship Association

Please note that the HPSA Collection Location Agreement is not a substitute for a commercial waste disposal service agreement.

* Required information

Before you Begin
Is your pharmacy licensed by the College of Pharmacists and open for operations?*
- Yes
- No
Please select one of the following:
Do you have a valid commercial waste disposal service agreement?*
- Yes
- No
Provide the name of your commercial waste service provider and account number*
Please submit the form once your pharmacy is licensed and open for operations.
Please submit the form once your pharmacy has a valid commercial waste disposal service agreement. Contact us at info@healthsteward.ca if you have questions.
Pharmacy Information
(As listed on College of Pharmacists)
Pharmacy Name*
Pharmacy Banner/Chain*

(e.g. Shoppers, Rexall, Independent)
College of Pharmacists Pharmacy Accreditation Number*
Contact Information
Pharmacy Manager Full Name*
First Last
Email Address*
Alternative Email
Phone Number*
Fax Number
Pharmacy Address
Pharmacy Address*
Street Address Unit/PO Box/RR# City Province Postal Code
Terms & Conditions
Please confirm that you have read and understood the agreement and that you agree to HPSA’s terms & conditions.
- I confirm that I have read and understood the agreement and that I agree to HPSA's terms & conditions.
Any information submitted on this form is for the sole purpose of HPSA in administering its programs. It will be protected and it will not be shared for any purposes outside of the administration of the services related to the programs.
- I agree to receive HPSA program updates
Name:*
Title:*
Date*
DD slash MM slash YYYY

(dd/mm/yyyy)
Please keep a copy of the email confirmation for your records. Make sure you check both your mailbox and your spam filter.
Name
This field is for validation purposes and should be left unchanged.

Collection Location Agreement – MB

Before you Begin

Pharmacy Information

Contact Information

Pharmacy Address

Terms & Conditions