Capital Locums - Pharmaceutical staff recruitment agency

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DISPENSER/TECHNICIAN REGISTRATION FORM

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

Dispenser/Technician 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

DOB

GENDER

NATIONALITY

DO YOU HOLD ANY OTHER QUALIFICATIONS?

NVQ2

NVQ3

ACT

OTHER

IF OTHER QUALIFICATION PLEASE ADD HERE

GPhC NUMBER (7 DIGITS)

QUALIFICATION DATE

NATIONAL INSURANCE NUMBER

IR35 compliance

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

HOW MANY MILES 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 QUALIFICATION CERTIFICATE

Upload file

DISPENSER/TECHNICIAN REGISTRATION FORM

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

Dispenser/Technician Registration

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