Registration assessment application Autumn 2018 sitting Application checklist I enclose with this form (please tick the boxes that apply): Photocopy of the photo I.D. you intend to take with you to the assessment (valid passport or UK/EU driving license (full or provisional)) Fee payment form (if you withdrew from your last assessment you will not have to pay again) Satisfactory third progress report (week 39) this must be the original document (this is only needed if this will be your first attempt at the assessment). Your tutor cannot sign this form until you have completed 39 weeks of training. Please retain a copy for your own records. Declaration by a supervising pharmacist following a six month placement only required if: a) This is your third attempt b) This is your second attempt and it has been more than 18 months since your last sitting c) More than 12 months has passed since you completed a six month period of supervised training Important: you must submit all the required documents by the advertised deadline date or your entry may not be processed. Post your form, using a traceable delivery method to: Pre-registration Assessment Entry Applications Customer Services General Pharmaceutical Council 25 Canada Square LONDON E14 5LQ Registration assessment application Autumn 2018 sitting Page 1 of 5
Registration assessment application form You will need to bring your valid passport or UK/EU driving licence to the registration assessment. Please write your name exactly as it appears on the I.D. document you intend to bring to the assessment, and a copy of which you have included with this application. Write in block capitals in the boxes provided. Your details Your pre-registration number Title Mr Mrs Ms Miss Other (please state) Your first name Your middle name(s) Your last name This matches the name on my training record Yes No This matches the name that I intend to register with Yes No (If your name does not match please submit a change of details form, which can be downloaded separately from our website). Address (this is the address where we will send assessment correspondence) Postcode Country Telephone number Email address We will send important information about the registration assessment by email. Registration assessment application Autumn 2018 sitting Page 2 of 5
Sitting information I confirm that I want to be entered for the Autumn 2018 assessment Which sitting will this be? (please tick one box): First Second Third I have separately applied for reasonable adjustments for this assessment: Yes No Important: applications for adjustments must be sent separately by the specified deadline. Declarations by applicant You must read and sign the two declarations below: I have read, fully understand and agree to be bound by the regulations for the GPhC registration assessment. The information I have given in this form has been provided to help the GPhC assess my eligibility to sit the registration assessment. I understand and accept that it may also be used by the GPhC in future in relation to determining an application for entry or renewal to the register or assessing my fitness to practise, and that updated information may be requested at any such time for these purposes. I declare that to the best of my knowledge all the information given on this form is true. I understand that any false statement will invalidate my entry. Signature of candidate I understand that I will need to bring a valid passport or a valid UK or European driving licence photo card, either full or provisional to be able to sit the assessment. Signature of candidate Registration assessment application Autumn 2018 sitting Page 3 of 5
Declaration by tutor If you are a first-time applicant you must get your tutor to fill in the following declaration: I confirm that (insert name of trainee) meets the qualifying criteria to sit the registration assessment, in line with the registration assessment regulations. Signed Please ensure you use the same signature as you entered on the trainee s learning contract Tutor s full name Email address GPhC number Date Data protection The GPhC is a data controller registered with the Information Commissioner s Office. Our full privacy policy is available on our website. You can find out more about your rights under the Data Protection Act 1998 from the ICO website. If you want to see personal information that we may hold about you, please send your request in writing to the Governance team at: Governance Team, General Pharmaceutical Council, 25 Canada Square, London, E14 5LQ or via email at foi@pharmacyregulation.org. You may be asked to give proof of your identity. Registration assessment application Autumn 2018 sitting Page 4 of 5
Payment form Name of applicant Preregistration number Please charge this card with: 1 8 2. 0 0 Please tick to say whether you are paying by: Important: You do not have to pay the assessment fee if you withdrew from your last assessment sitting, and had already paid the entry fee (conditions apply). If you think this applies to you, please tick the box. You do not need to give your card details. Debit card Credit card Type of card (Please tick one) Mastercard Visa Card number (Insert the exact number of digits in your card number only) CSC number (The last 3 digits on the back of the card) Valid from date Expiry date Name of cardholder The name exactly as it appears on the debit or credit card Address of cardholder Postcode Signature Date To be signed by the cardholder Registration assessment application Autumn 2018 sitting Page 5 of 5