College of Pharmacists of Manitoba 200 Tache Avenue, Winnipeg, Manitoba R2H 1A7 Phone (204) 233-1411 | Fax: (204) 237-3468 E-mail: [email protected] | Website: www.cphm.ca Location: University of Manitoba, College of Pharmacy (Faculty) Apotex Centre, Main Floor Lecture Theatre, Room 164 (tentative) Schedule: 8:00 A.M. – 8:30 A.M. Registration 8:30 A.M. – 4:30 P.M. Workshop (includes breaks and lunch) Name: License Number: Daytime Telephone: Email Address Prior to attending the Principles for the Provision of Opioid Dependence Treatment by Manitoba Pharmacists Certificate Program, participants are required to:   Read the Principles for the Provision of Opioid Dependence Treatment Guidelines (accredited for 2.00 CEU) available on the College website here Watch (or have previously attended) the University of Manitoba, Faculty of Medicine, Office of Continuing Professional Development DVD – Methadone – An Introduction to Clinical Practice (accredited for 5.00 CEU) available for viewing by emailing [email protected]  Professional Declaration to Completion of Prerequisites: I, _________________________________________ of ________________________ in the Province of (Name) (City or Town) ________________________ declare that I have completed the Principles for Provision of Opioid (Province) Dependence Treatment by Manitoba Pharmacists Certificate Program prerequisites as outlined above. I make this professional declaration conscientiously believing it to be true. Declared this______ day of__________________ , 2015 . (Date) (Month) ________________________________________________________________________ ( Signature) Please provide the College office with the completed form by email: [email protected], fax: 204-237-3468, or drop it off at 200 Tache Ave, Winnipeg, MB. Payment details must be provided to the College via telephone in order to secure a spot in the program. Updated May 13, 2015