Please complete the boxes below and click on Send to e-mail the Registration Page to us. All information collected and used by Nightingale Pharmacy Services is used in accordance with the Data Protection Act 1998. Please refer to our Data Protection Policy for further information.

 I wish to register as a Locum Pharmacist        I wish to register as a Locum Technician      GPhC Registration Number 

 Mr/Mrs/Miss/Ms/Dr      First Name Middle Name   Surname 

House/Flat number        Street/Road Town/City      Post Code

 

Date of birth               Nationality                  NI no     Own Transport 

 

CONTACT DETAILS

E-mail address         Mobile Number    Home Telephone 

Are you currently employed by any other company? (If so, please specify) 

Please specify any company/organisation you do not wish to work for.       

If you work with/are registered with any other agency, please specify.        

 

PREFERRED WORKING ENVIRONMENT

Community Independents    Community Multiples     Hospital      HM Prison    Other (Please specify)

Items/day   Dispenser   Addicts  Needle Exchange   EHC MUR/NMS   MAS   SCR

 

Dementia Friend   Smart CardNHS FLU SERVICE PRIVATE FLU SERVICE   Indemnity Insurance     Policy number

Other relevant skills/qualifications

COMPUTER SYSTEMS

Nextphase   Pharmacy Manager Proscript   Compass    Smartscipt   Other (please specify)

 

PERSONAL REQUIREMENTS

Required Hourly rate (£ weekdays)   (£ weekday evenings)   (£ Saturdays)    (£ Sundays) (£ Other )

Mileage rate (pence per mile*)        * Some companies do NOT pay any mileage, other deduct fixed amounts e.g. first 40 miles of total travel.


Are you prepared to work away from home if suitable accomodation is provided  


REFERENCES


Please provide details of two people who can provide work based/professional references for you.


REFERENCE 1
Title    First Name    Surname    Position/Job Title 

 

E-mail       Phone   Fax (If applicable)  

Address Line 1    Address Line 2    Town/City Post Code 

REFERENCE 2

Title  First Name     Surname Position/Job title    

E-mail     Phone       Fax (If applicable)


Address Line 1  Address Line 2    Town/City   Post Code


EVIDENCE OF IDENTITY

Please forward copies of your I.D. via e-mail to  admin@nightingalepharmacyservices.com  to comply with U.K. Government laws and requirements. No information will be shared or released to any third party EXCEPT where required by law to statutory bodies e.g. H.M.R.C., U.K. Visas and Immigration.

Passport/Driving Licence Photo ID      Indemnity Insurance    Leave to Remain (where applicable)


ACCEPTANCE OF NIGHTINGALE PHARMACY SERVICES TERMS AND CONDITIONS AS PUBLISHED ON THIS WEBSITE


I confirm that I have read, accept and understand in full the terms and conditions as stated above. 

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