Pharmacist Registration Form

PHARMACIST REGISTRATION

Please complete the pharmacist registration form below so we can process your application.

(* denotes a required field)

Title

If other please specify

First name

Last name

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Phone

Email Address

GPhC Number (7 DIGITS)

Qualification Date

Are you an Independent Prescriber?

Yes

DOB

Day

Month

Year

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 Visa/Residence Permit

Upload DBS Enhanced Disclosure

Upload Safeguarding Level 2

Upload Other Accreditation 1

Upload Other Accreditation 2

Upload Other Accreditation 3

Upload Vaccination Certificates

Pharmacist T&Cs

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

Privacy Policy

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