Pharmacist Registration

PHARMACIST REGISTRATION

Please complete the pharmacist registration form below so we can process your application.
(* denotes a required field)

Pharmacist Registration

TITLE

IF OTHER PLEASE SPECIFY

FIRST NAME

LAST NAME

ADDRESS LINE 1

ADDRESS LINE 2

ADDRESS LINE 3

TOWN

COUNTY

POSTCODE

MOBILE NUMBER

EMAIL ADDRESS

GPhC NUMBER (7 DIGITS)

QUALIFICATION DATE

ARE YOU AN INDEPENDENT PRESCRIBER?

YES

DOB

GENDER

NATIONAL INSURANCE NUMBER

IR35 compliance

I confirm that I am IR35 compliant and responsible for my own Tax and National Insurance Contributions

NATIONALITY

HOW FAR ARE YOU WILLING TO TRAVEL FOR WORK?

MINS/MILES

MEANS OF TRANSPORT

Public Transport

Car/Motorbike

Walking

Bicycle

PROFESSIONAL REFERENCE 1 NAME

PROFESSIONAL REFERENCE 1 PHONE NUMBER

PROFESSIONAL REFERENCE 1 DETAILS

PROFESSIONAL REFERENCE 2 NAME

PROFESSIONAL REFERENCE 2 PHONE NUMBER

PROFESSIONAL REFERENCE 2 DETAILS

UPLOAD PASSPORT COPY

Upload file

UPLOAD VISA/RESIDENCE PERMIT

Upload file

UPLOAD DBS ENHANCED DISCLOSURE.

Upload file

UPLOAD SAFEGUARDING LEVEL 2

Upload file

UPLOAD OTHER ACCREDITATIONS 1

Upload file

UPLOAD OTHER ACCREDITATIONS 2

Upload file

UPLOAD OTHER ACCREDITATIONS 3

Upload file

UPLOAD VACCINATION CERTIFICATES

Upload file

PHARMACIST T&Cs

Please check this box to confirm that you have read and agree to the Capital Locum pharmacist terms and conditions.

Please check this box to confirm that you have read and agree to the Capital Locum data and privacy policy.