Locum Registration
Please complete the form below to register with us.

Once you have entered your information, you must click Send
After clicking Send you will then be taken to the Reference page to complete.


Fields are mandatory to complete otherwise they will be marked *Optional
Page 1 of 2 To be completed

Your GPhC Nos        
Locum Title:         
First Name:            
Middle Name:         *Optional
Surname:               
House No:              
Street:                   
Town or City:          
County:                  
Postcode:               
Locum Country:      
Home Telephone Number:     *Optional
Work Telephone Number:      *Optional
Mobile Telephone Number:    

Are you a Car Driver:                      
Locum Email:                                   
Locum National Insurance Number:   
Your Employment status Self Employed:
Your Tax Reference Number:           
Type of Employment 1st Choice:    
Type of Employment 2nd Choice:   

Locum SMS Sign Up:   
Locum Community:     
Locum Multiples:        
Locum Independents:  
Business/Organisation do you not want to work for:  *Optional
Area you want to work in:  
Travelling Distance willing to work:  in miles    
Kind of Transport:

Normal Hourly Rate Required:         £  
Saturday Hourly Rate Required:       £  
Sunday Hourly Rate Required:         £   
Emergency Hourly Rate Required:    £  
Evening Hourly Rate Required:        £  
Mileage Rate Required:                     p  
Will you negotiate on Mileage Rate?:  

Professional Indemnity Policy:     
Repeat Dispensing:                 Personal Smartcard:        
EHC under PGD:                      Minor Ailments:              
Smart Script Boots:                 Nextphase:                     
Mediphase:                             Lloyds PMR:                    
NDC Pharmacy Manager:          Alchemist:                      
JRC:                                       Hadley Hutt:                   
Link:                              

Other Computer Systems    *Optional (250chars max)
Other Accreditations          *Optional (250chars max)          

Has Declaration been read Read it Here  
Signature:                                             

 
We need a copy of your Driving Licence/Birth Cert/Passport: 
Any Relevant Certs 1:           *Optional
Any Relevant Certs 2:           *Optional
Any Relevant Certs 3:           *Optional
We need proof of your Taxable State:                             
We need a copy of you Professional Indemnity Cert:         
We need a copy of Overseas Right to Work in UK (if app):
 
Send Now      Cancel  

If anything shows up in Red below, these fields have NOT been completed and need you to fill in.
          
       
        
     
     
 
After clicking Send Now you will continue with your Registration process
All information is treated in the strictest of confidence and used only for the purpose
of securing work placements/employment.
We are required to ask for certain information by statutory bodies e.g. HMRC, Borders Agency etc.