Locum registration

Personal Information

Title
*First Name:
*Surname:
*Gender:	Male Female
*Nationality:
*Date of birth: (format: dd/mm/yyyy)
*Email:	- this will be used for your login
*Address:
*City/Town:
County:
*Postcode:
*Telephone:	- include your area code
Mobile:

Eligiblility to Work within UK

Are you a British National or a national of an European Community Country?
Do you require a work permit to work in UK? (If yes, please supply a copy of the work permit)
Have you permanent residence status in UK? (If No, please supply a copy of your work visa)

Pharmacy Qualifications

*RPSGB number:
*Date of Registeration: (format: dd/mm/yyyy)
School of Pharmacy attended:

Professional Indeminty Insurance

Do you have Professional Indemnity Insurance?
(If Yes, please supply a of insurance certificate)

Do you hold a NHS smart card?