Applicants with the currently approved GPhC qualifications and work experience

Transcription

1 Application form and Guidance notes on how to apply for registration as a pharmacy technician with current GPhC approved qualifications and work experience August GPhC Dec

2 This registration guidance should provide you with all the information you need about how to register. Please read this carefully before contacting the General Pharmaceutical Council (GPhC). You can submit your application no sooner than 4 weeks before you are due to complete the relevant work based experience. For example if you are applying with UK qualifications only (with no overseas qualification) and you started the 2 years work experience on 1 September 2009, the earliest you can submit your application is during the first week of August Please note the application you submit must be complete and include all supporting documents and qualification certificates correctly certified by a solicitor or a commissioner of oath. Incomplete applications will be returned to you and where we require additional information this may delay your registration. If you do submit an application before you complete the relevant work based experience your supervising pharmacist must complete the additional declaration confirming the date when the period will finish. Due to Crown Copyright, from the 5 th February 2013 the GPhC will not be able accept certified copies of Birth Certificates from anyone born in the UK. This also applies to certified copies of marriage certificates. You will now need to provide, with your application, a duplicate birth certificate issued by General Register Office as proof of your date of birth, and a duplicate marriage certificate issued by General Register Office if required. This document will not be returned to you and will be held on record by the GPhC. We strongly advise that you do not provide your original birth & marriage certificates, but instead apply for a duplicate of the document(s) as they will not be returned to you. If you were born in England or Wales you should contact the General Registers Office (or General Registers Office for Scotland if you were born in Scotland), so that you can apply for a duplicate directly from them. If you were born in the UK you should not be able to obtain a certificated copy of your Birth Certificate and will not be accepted by the GPhC. If you do supply, a certified copy, it will delay your registration while you obtain an original General Register Office Birth Certificate as proof of your date of birth. The same will also apply for marriage certificates. If you were born outside the UK you should still provide a certified copy as outlined in the registration guidance notes. Completed forms must be sent to Pharmacy Technician Registration, General Pharmaceutical Council, 25 Canada Square, London E14 5LQ. The GPhC enters applicants onto the register on the 1 st and 15 th date of each month. You will not have access to your registration number until the date that you are due to register (as of a.m. on that day). You can obtain your registration number from the GPhC website by doing a pharmacy technician search and entering your name. A few weeks after you have been registered, a letter will arrive confirming your registration. This will confirm the part of the register in which you have been registered, your name as it appears on the Register, your registration number, the date of entry on the Register and the period that your entry is valid. The GPhC does not issue certificates. Your registration number is proof of registration with the GPhC.

3 Preparing and completing your application 1. Read all the guidance carefully. 2. Complete the application form in BLOCK CAPITALS and mark boxes clearly to answer the questions. 3. Check the guidance if you are not sure how to answer a question. Additional guidance documents are listed below. Contact us if you are still not sure how to answer a question. 4. Using the Registration application checklist, collect together all your certificates and passport. See below for alternatives to current passports. 5. If you are applying and have a non-uk pharmacy qualification as well as the 2 approved UK qualifications, there are additional documents you will need to send. 6. Check that all the names on your documents are spelt the same way and any changes in name can be tracked. If there are variations see below for advice. 7. Arrange to visit a UK practising solicitor or commissioner of oath to obtain certified photocopies of the original documents you need to submit. 8. Arrange for your photograph and section 9 of the form to be signed (your countersigning pharmacist or pharmacy technician can sign if they have known you for at least 2 years). 9. Arrange to meet with the pharmacist/pharmacy technician who will countersign your application form. 10. Before meeting your pharmacist/pharmacy technician, check you have answered all the questions in the application form. Using the checklist, check you have provided all the necessary copies of documents. 11. Once you have signed section 7 yourself, your countersigning pharmacist or pharmacy technician should check your application thoroughly before signing section 8 A of your form. 12. Send your completed application to us as instructed on the checklist. 13. It is important that your application is double checked before sending it to us. 14. If any information or documents are missing we will return your application and your registration will be delayed. We will charge a 47 administration fee if we have to return applications for missing information more than once.

4 Additional guidance documents and forms The following documents can be downloaded from our website Guidance: Standards of conduct, ethics and performance Standards for continuing professional development Criteria for the initial registration as a pharmacy technician Guidance on registration with the GPhC and Fitness to Practise: This advises how to answer the questions on fitness to practise Good character assessment framework: This lists the areas we will take into consideration when you have declared a conviction or police caution Health assessment framework: This lists all the relevant points we will take into consideration when you have declared matters concerning your health. Additional forms: Something to declare form. To be completed if you have declared a conviction, caution or health matter.

5 Registration application checklist Application form (including photograph certification) Payment form Birth certificate original copy from applicants born in the UK or certified copy for applicants born overseas (and/or statutory declaration) Marriage certificate/s (if you are married) original copy from applicants born in the UK or certified copy for applicants born overseas (or statutory declaration) Certificates for the competency based and knowledge based qualifications and non-uk qualification (if applicable) certified copies Passport certified copy or alternative documents Photograph attached to section 9 of the application form Stamped self addressed postcard for confirmation that we received your application If you have a non-uk pharmacist or pharmacy technician qualification and want to use evidence of this to reduce the 2 year qualifying period of work experience required you must arrange for the following documents to be sent direct to the GPhC Academic transcript relating to your qualification. This must be sent to the GPhC by your awarding institution (college/university) Evidence that you are registered or otherwise eligible to practise as a pharmacist or pharmacy technician in the country of your qualification. You must arrange for the regulatory authority or awarding institution to confirm this direct to the GPhC. If the profession is regulated in your country of qualification this is normally in the form of a letter of good standing or certificate of current professional status. Send your completed forms and other documents to: Pharmacy Technician Registration General Pharmaceutical Council 25 Canada Square London E14 5LQ We will only accept complete applications. Both declarations (see sections 7 and 8) must be signed and supporting documents included with your application form. We will not accept liability for any loss as a result of completed applications not reaching us. Recorded delivery is recommended. Keep a copy of your application in case the original does not reach us. A stamped addressed postcard must be enclosed with your application for us to acknowledge receipt. Applications can take as long as 4 weeks to process. This can be much longer if you have disclosed a fitness to practise matter.

6 How to complete the application form Section 1 Personal details Questions 1.2 and 1.3 Names The name you register under must be the same as the name you intend to practise under. This will be your registered name. If you wish to be registered in a different name from that printed on your birth certificate you must provide either: An original copy of your marriage certificate or other acceptable documentation (for instance a Deed Poll or certificate of Civil Partnership), or A statutory declaration completed in front of a solicitor. A statutory declaration form is provided at the end of the application pack. Your name on all the documents you submit must be exactly the same letter for letter, word for word. If there are any variations in your name within or between documents you must provide a declaration of those variations on the Statutory Declaration form, sworn before a solicitor registered and in good standing, with the Law Society of England and Wales or Scotland who is practising in one of those jurisdictions. Please tell us if you change your name. If you change your name whilst we are processing your application, you must notify us in writing and send a certified photocopy of the relevant document (for instance a statutory declaration or original marriage certificate). If you change your name after you are registered, you must notify us in writing within one month of the date of change with a certified copy of the relevant document. Question 1.5 and 1.6 Your address Your registered address must be the address where you live, as this is the address we will use when we write to you. We will not publish this address on the publicly available Register. Please provide us with an address. We will contact you by if we require additional information or documents. You must keep your contact details up to date. If you change your home or address you must notify us as soon as possible. If you fail to keep your contact details up to date and we cannot contact you for clarification this will delay your application.

7 Section 2 Application type Please tell us what type of applicant you are by ticking the appropriate box on the application form. Section 3 Previous applications and Registration with other bodies Question 3.1 Previous applications You must tell us if you have previously: registered with the Royal Pharmaceutical Society of Great Britain (RPSGB) or the GPhC in the past as a pharmacist or pharmacy technician applied for registration with the RPSGB or GPhC as a pharmacist or pharmacy technician undertaken or applied to RPSGB or GPhC for pre-registration training. If any of the above applies, you must also tell us: the date of your application the type of application (for instance, was it made through transitional provisions, as an international application or were you applying to register as a pharmacist) any previous registration or pre-registration numbers or application numbers you may have had any other information you think is relevant (for instance, if you began an application but then withdrew). Questions 3.2 You must tell us if you are, or have been, registered with any other regulatory bodies either in the UK or overseas. If you are registered with more than one body please provide details on a separate sheet. If you are relying on your non-uk qualification for registration you must arrange for a letter of confirming your registration status and/or eligibility to practise to be sent directly to us by the issuing authority. Section 4 Fitness to Practise We define a conviction as a finding, in criminal proceedings in the UK (or elsewhere), that a person has committed the offence alleged. You do not need to include road traffic offences where you were offered the option of paying a fixed penalty. This is even if you refused the option of paying the fixed penalty and were convicted of the offence by a court. You must tell us if you have been involved in any legal or disciplinary proceedings including any that have resulted in a caution or if you have any problems with your physical or mental health that may impair your ability to practise. Failure to do so may result in misconduct allegations at a later stage. You must tick either yes or no to questions 4.1 to 4.7. If you have answered yes to any of the questions you must complete the Something to declare form.

8 Section 5 Education and training Approved UK qualifications You must hold: One of the competency qualifications and One of the knowledge qualifications The eligible qualifications are listed in Annex A of the Criteria for initial registration as a pharmacy technician. Only include the UK qualifications listed in Annex A which you hold and not pharmacy/dispensing assistant or medicines counter assistant qualifications. For each of the qualifications, write the exact title of the qualification, the date you started your course and the date you were awarded your qualification. If you hold a non-uk pharmacy qualification, in addition to the 2 approved UK qualifications, and wish to rely on this to reduce the 2-year qualifying period of work experience you must tell us: the title of this qualification, the name of the awarding institution and the country where your qualification was obtained.

9 Section 6 Qualifying periods of work experience You need to provide evidence of having completed a minimum of two years relevant work-based experience in the UK under the supervision, direction or guidance of a pharmacist to whom you have been directly accountable for not less than 14 hours per week. Within this 2 year period there must be at least 1260 hours of work experience in total and there must be a minimum of 315 hours in each of the two years. This duration in hours excludes sickness absence, maternity/paternity leave and holidays. (Please see section 7 of the GPhC Criteria for initial registration as a pharmacy technician on the GPhC s website for further information). You can include work experience, during your pharmacy technician courses and up to 3 months before the start of the course, provided that during this time you have been working and carrying out the role of a pre-registration trainee pharmacy technician in the United Kingdom, Isle of Man or Channel Islands under the supervision, direction or guidance of a pharmacist to whom you have been directly accountable. This is because within 3 months of commencing contracted relevant work experience as a pre-registration trainee pharmacy technician you must commence or register for one of the two required qualifications listed above. If there are gaps in your work experience, e.g. due to maternity leave, you will need to give a brief explanation in a covering letter. If there are variations in your hours over the two years, please provide details on a separate sheet. If you have told us that, you hold a non- UK pharmacy qualification and that you have completed One of the competency based qualifications and One of the knowledge based qualifications (listed in Annex A of the Criteria for initial registration as a pharmacy technician). You are not required to complete the full 2 years relevant work experience in the UK if you provide evidence: that you have relevant work-based experience in the UK as a pre-registration trainee pharmacy technician under the supervision, direction or guidance of a pharmacist to whom you have been directly accountable for not less than 14 hours per week whilst you have been completing the two approved UK qualifications. You can include work experience, during your pharmacy technician courses and up to 3 months before the start of the course, provided that during this time you have been working and carrying out the role of a preregistration trainee pharmacy technician in the United Kingdom, Isle of Man or Channel Islands under the supervision, direction or guidance of a pharmacist to whom you have been directly accountable; and that you hold a non-uk pharmacist or pharmacy technician qualification. You must arrange for your awarding institution to send direct to the GPhC the academic transcript relating to your qualification; and that you are registered or otherwise eligible to practise as a pharmacist or pharmacy technician in the country of your qualification. You must arrange for the regulatory authority or awarding institution to confirm this direct to the GPhC. If the profession is regulated in your country of qualification this is normally in the form of a letter of good standing or certificate of current professional status.

10 Section 7 Declaration by applicant You must sign and date the declaration. The GPhC register is divided into parts. Part 2 is for registration as a pharmacy technician. Fraudulently procuring an entry in the pharmacy technicians register will be treated as misconduct and may result in removal from the Register. Section 8A Declaration by countersigning pharmacist or pharmacy technician This section must be completed by a practising pharmacist/pharmacy technician with current UK registration who is in good standing. The pharmacist s/pharmacy technician s registration number must be provided so we can verify their details. The countersignatory is asked to declare that to the best of their knowledge the information given in the application and in any supporting information is true and accurate, and relates to you. If you are sending your application in advance of having completed the relevant period of work experience Section 8B must be completed by the pharmacist under whose supervision, direction or guidance you have been working in the UK and to whom you have been directly accountable. Section 9 Photograph certification guidance You must provide one recent passport sized photograph. This must be signed on the back by an appropriate official. The photograph must be attached to the photograph certification page of your application form. The person who signs the photograph (the counter signatory): Must be a professional person, or a person of standing in the community. Examples include a pharmacist, registered pharmacy technician, a UK registered solicitor or a licensed Medical Practitioner. If you have any questions about who is an appropriate official contact us. Must have known you for at least 2 years Must not be related to you by birth or marriage. Neither should they be in a personal relationship with you e.g. husband and wife, nor live at your address Must write on the back of the photograph the words I certify that this is a true likeness of (give full name of the applicant) They must also sign and date the back of the photograph They must also complete the photograph certification page of the application form giving their full name, occupation and sign and date the form. Section 9 and the photograph must be signed on the same date.

11 Requirements for the photograph The photograph must be: Taken within the last month In colour Against off-white, cream or light grey plain background so your features are clearly distinguishable Printed on low-gloss, plain-white photo-quality paper Undamaged, for example, by creases from paperclips Of you on your own In sharp focus and clear Have a strong definition between face and background. The photograph must show: No shadows You facing forwards, looking straight towards the camera A neutral expression, with your mouth closed (no obvious grinning, frowning or raised eyebrows) Your eyes open and clearly visible (no sunglasses or heavily tinted glasses and no hair across your eyes) No reflection or glare on your glasses, and the frames should not cover your eyes Your full head, without any head covering, unless it is worn for religious beliefs or medical reasons Nothing covering your face. Please ensure that nothing covers the outline of your eyes, nose or mouth.

12 Section 10 Equality Monitoring Form You are not required to provide this information if you do not wish to do so but would be helpful if you do. Section 11 Payment for application for registration as a pharmacy technician When you apply to register with us you need to pay the appropriate fees. An application fee. This covers our costs for checking the documents you have provided The first entry fee. This covers our costs for putting and maintaining your name on the register for 12 months from the date of entry. You need to submit both the application fee and the first entry fee with your application. Please note you: must make your payment by credit or debit card as we no longer accept cheque payments should complete the Payment Form included in the application pack providing your card details will not be registered as a pharmacy technician until we have taken the first entry fee payment. If you send in your application without the correct fees your application will be returned to you.

13 Guidance on providing supporting documents You will be required to visit a solicitor and additionally you will need to contact the General Register Office (GRO). Certified copies We recommend you send certified copies (not the originals) of the following documents: Evidence of name change document(s) (where appropriate) [excluding a marriage certificate] Passport. If you do not have a current passport - see advice below Qualification certificate(s). Only UK registered solicitors can certify your documents. The official must write on each photocopy: I certify that I have seen the original document and that this is a true copy sign, print name and provide SRA number date and provide an official solicitor s stamp. No liquid paper amendments or alterations of any other kind are permitted to certified copies. Original duplications from the General Register office Marriage certificate Birth certificate. Please see reference 1 in footer below Changes in name All the names on your birth certificate, passport, qualification certificate and application form must be exactly the same, which means word for word, letter for letter. This includes any middle names or initials you may have and any changes in spelling or order. You must provide documentation to support all changes to your name, for instance a marriage certificate, Deed Poll or Certificate of Civil Partnership. If you are not able to do this, you must see a solicitor and complete the relevant section of the statutory declaration form. Reference 1: Due to Crown Copyright, from the 5 th February 2013 the GPhC will not be able to accept certified copies of Birth Certificates from anyone born in the UK. This also applies to certified copies of marriage certificates. You will now need to provide, with your application, a duplicate birth certificate issued by General Register Office as proof of your date of birth, or a duplicate marriage certificate issued by General Register Office if required. This document will not be returned to you and will be held on record by the GPhC.

14 Translations for documents not in English Any document that is not written in the English language MUST be accompanied by a translation. You must provide the original translation together with a solicitor certified copy of the document which is not in English. Translations must be carried out by a professional translator. The translator must sign and date the translation and provide their name and business address. The translator must also certify that they are authorised to translate from the particular foreign language into English, and that the translation produced is true and accurate. The certification must be on the same page as the translation or be attached to the translation. The translation must be a literal translation NOT an interpretation of the original document. All certifications and ink stamps on the original document must also be translated. Contact your embassy for a list of official translators.

15 Applicants without passports If you do not have a current passport you should send certified copies of both your: UK driving licence (Full or Provisional), AND NHS card (must have your full names, DOB, details of the GP Practice and/or name of your GP ) or National Insurance card. Both the photo card and paper part of the driving licence must be provided. The driving licence must be current. If you do not have a current photo card driving licence you should send: NHS card or a National Insurance card (certified copy), AND three of the following original documents (we will return them to you by recorded delivery) o Bank/building society, credit card or financial statement (such as a pension statement) o P45/P60 o Utility bill o TV licence o Addressed payslip o Council tax or benefit statement o CRB disclosure certificate All documents must be dated within the last 12 months of the date your application is received by us. The details on the document (including address) must be the same as the details on your application form.

16 Academic Transcripts for overseas qualifications An academic transcript is a full transcript of your academic record for your pharmacy qualification. It must show the years of study, the subjects you studied and the marks you obtained in each examination. It must be certified by the relevant officer at the university or academic body. Letters of good standing Evidence of being registered should be provided in a Letter of Good Standing or Certificate of Current Professional Status issued by the appropriate authority of the country or state in which you originally qualified. The certificate should be issued no more than six months before the date that you expect to apply to register. If you have practised within the last five years in countries or states other than that in which you qualified you are also required to provide a Letter of Good Standing or Certificate of Current Professional Status issued by each appropriate authority of every such country or state. If you have not maintained your overseas registration, then you are required to obtain a certificate from all of the relevant authorities confirming the following: That you are no longer registered with that authority, but that the qualification you hold entitles you to register AND That if you wanted to re-register in the future, then there are no matters of a disciplinary or criminal nature existing, and no pending disciplinary or criminal investigations, which would prevent the authority from re-registering you and permitting you to resume practice as a pharmacy professional within their jurisdiction. What is a Statutory Declaration? When submitting your registration documents, please bear in mind that the names on your birth certificate, qualification certificate, proof of identity document(s) and application for registration must be identical in every way. That includes any middle names or initials you may have and any changes in spelling or order. If the names on these documents are not identical, you must see a solicitor and complete the relevant sections of the Statutory Declaration. Failure to do this will delay your registration. If any of the following apply, you will need to see a solicitor to complete a Statutory Declaration: You do not have a Birth Certificate or your Birth Certificate is not written in English. COMPLETE DECLARATION A The registration date on the Birth Certificate is not within one year of the date of birth. COMPLETE DECLARATION A You want to register in a name other than that on your Birth Certificate, e.g. additional/dropped names or letters. (The name you put on the Statutory Declaration should be identical to that which you put on your Application for Registration Form.) COMPLETE DECLARATION B Names on your qualification certificates or Proof of Identity Document(s) are not identical in every way to those on your Birth Certificate and Application for Registration Form. (All names must be identical: word for word, letter for letter and in the same order. Initials are not acceptable.) COMPLETE DECLARATION C

17 Application form for registration as a pharmacy technician THIS APPLICATION FORM IS FOR APPLICANTS APPLYING WITH THE CURRENT GPhC APPROVED QUALIFICATIONS AND WORK EXPERIENCE. Pharmacy Technician Registration, General Pharmaceutical Council 25 Canada Square, London E14 5LQ info@pharmacyregulation.org

18 Official use only: THIS APPLICATION FORM IS FOR APPLICANTS APPLYING WITH THE CURRENT GPhC APPROVED QUALIFICATIONS AND WORK EXPERIENCE. PLEASE NOTE APPLICATIONS MAY TAKE AT LEAST 4 WEEKS TO PROCESS. 1. Personal details 1.1 Title Mr Mrs Ms Miss Other (please specify) 1.2 Surname(s) 1.3 Forename(s) 1.4 Date of birth / / 1.5 Home Address 1.6 Postcode Country 1.7 Nationality 1.8 Home phone Work phone 1.9 Mobile address

19 2. Type of application 2.1 Which application process applies to you (Please tick one box) Applicant with approved UK qualifications and 2 year qualifying period of work experience Applicant with approved UK qualifications and evidence of non-uk pharmacy qualification and qualifying period of work experience 3. Previous applications and Registration with other bodies 3.1 Have you ever applied previously for registration with the Royal Pharmaceutical Society of Great Britain (RPSGB) or the General Pharmaceutical Council (GPhC), either as a pharmacy technician or as a pharmacist or undertaken preregistration training with the RPSGB or the GPhC? If you have answered yes to question 3.1 please state your application, registration or preregistration number/ type of application/ date of application / / Yes No 3.2 Are you currently or have you previously been registered with any UK statutory health regulatory body (any member body of the Council for Healthcare Regulatory Excellence) or a health regulatory body outside Great Britain? Yes No If you have answered yes to question 3.2 please give details and provide a letter of good standing Name of body Registration number

20 4. Fitness to practise By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and the Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Order 2003, you are exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act Therefore you are not entitled to withhold information about convictions which for other purposes are spent under the provisions of the Act and failure to disclose such convictions could result in disciplinary action 4.1 Has a determination ever been made against you by a regulatory body in the United Kingdom responsible under any enactment for the regulation of a health or social care profession to the effect that your fitness to practise as a member of a profession regulated by that body is impaired, or a determination by a regulatory body elsewhere to the same effect? Yes No 4.2 Do you currently have any problems with your physical or mental health that may impair your ability to practise safely and effectively or which otherwise impairs your ability to carry out your duties in a safe and effective manner? Yes No 4.3 Have you previously been convicted or cautioned for a criminal offence in the British Islands or elsewhere (which, if committed in England, Scotland or Wales would constitute a criminal offence) or have you previously agreed to be bound over to keep the peace by a Magistrates Court in England or Wales? Yes No Please note that Road Traffic offences in which the person committing the offence has been offered the option of paying a fixed penalty (e.g. certain speeding offences etc) will not be treated as a conviction for the purposes of registration and need not be declared. 4.4 Have you previously agreed to pay a penalty under section 115A of the Social Security Administration Act 1992 (penalty as alternative to prosecution)? Yes No 4.5 Are you currently under investigation by any regulatory body (other than the GPhC) or criminal enforcement authority (e.g. police or NHS Counter Fraud Service) in the British Islands or elsewhere? 4.6 Have you previously accepted a conditional offer under section 302 of the Criminal Procedure (Scotland) Act 1995 (fixed penalty: conditional offer by procurator fiscal) or have you previously been subject to an order under section 246(2) or (3) of the Criminal Procedure (Scotland) Act 1995 discharging you absolutely (admonition and absolute discharge)? Yes No 4.7 Have you previously been included by the Independent Safeguarding Authority (also known as the Independent Barring Board) barred list (in England, Wales or Northern Ireland) or the children s list or adult s list maintained by the Scottish Ministers? Yes No If you have answered yes to any of the questions please provide details on the Something to Declare form with your application. The something to declare form is available on our website by to info@pharmacyregulation.org and by telephone on Yes No

21 5. Education and training Applicants should provide details of pharmacy technician qualification(s) gained in the United Kingdom. Applicants must hold one of the approved competency based qualification and one of the approved knowledge based qualification and provide solicitor certified photocopies of all relevant qualification certificates with their application. 5.1 Title of knowledge based qualification 5.2 Date commenced (month and year) / 5.3 Date awarded (month and year) / 5.4 Name of course provider 5.5 Title of competency based qualification 5.6 Date commenced (month and year) / 5.7 Date awarded (month and year) / 5.8 Name of course provider 5.9 Title of non-uk pharmacy qualification (if applicable) 5.10 Date commenced (month and year) / 5.11 Date awarded (month and year) / 5.12 Name of university 5.13 Count

22 6. Work experience Provide information on your work experience as a pre-registration trainee pharmacy technician. You must provide evidence of having completed a minimum of two years relevant work-based experience in the UK under the supervision, direction or guidance of a pharmacist to whom you have been directly accountable for not less than 14 hours per week. (Please see section 7 of the GPhC Criteria for initial registration as a pharmacy technician). During these two years, you must have completed at least 1260 hours of work experience (excluding sickness absence, maternity leave and holidays) and at least 315 hours of work experience in each year. You can include work experience during your pharmacy technician courses and up to 3 months before the start of the course provided that during this time you have been working and carrying out the roles of a pre-registration trainee pharmacy technician in the United Kingdom, Isle of Man or Channel Islands under the supervision, direction or guidance of a pharmacist to whom you have been directly accountable. If you have a non-uk pharmacy qualification you have to provide evidence of this (see guidance notes) and of having worked in the UK as a pre-registration trainee pharmacy technician under the supervision, direction or guidance of a pharmacist to whom you have been directly accountable for not less than 14 hours per week. Gaps in work experience - you must tell us if there are any gaps in your work experience, e.g. maternity leave, long term sick leave. On a separate sheet or covering letter, give a brief reason for the gap and start / end date. A. Work experience in year 1 Name and address of organisation Hours worked per week, Provide details on a separate sheet if there is a variation Start date (dd/mm/yy) / / End date (if applicable) (dd/mm/yy) / / Job Title Main responsibilities / duties Name and job title of your supervising pharmacist and their GPhC registration number Contact number of supervising pharmacist

23 B. Work experience in year 2 Name and address of organisation Hours worked per week Provide details on a separate sheet if there is a variation Start date (dd/mm/yy) / / End date (if applicable) (dd/mm/yy) / / Job Title Main responsibilities / duties Name and job title of your supervising pharmacist and their GPhC registration number Contact number of supervising pharmacist

24 C. Any additional work experience to complete approved UK qualifications or work experience requirement Name and address of organisation Hours worked per week Provide details on a separate sheet if there is a variation Start date (dd/mm/yy) / / End date (if applicable) (dd/mm/yy) / / Job Title Main responsibilities / duties Name and job title of your supervising pharmacist and their GPhC registration number Contact number of supervising pharmacist Please continue you career history on separate sheets if necessary

25 7. Declaration by applicant This declaration must be completed and dated before you give your application and supporting documents to the countersignatory for checking. I declare that: 7.1 I am applying for registration in Part 2 of the Register and I hereby declare that, in accordance with Article 20(3) of the Pharmacy Order 2010, I intend to practise as a pharmacy technician in Great Britain, the Channel Islands or the Isle of Man. 7.2 The information that I have provided in this application for registration is complete, true and accurate. I am also aware that I am under a duty to notify the Registrar of any changes to my name, home address or other contact details within one month starting on the day on which the change occurred. 7.3 I will adhere to the standards relating to conduct, ethics and performance and continuing professional development published by the General Pharmaceutical Council. 7.4 I have in place appropriate indemnity arrangements. 7.5 I accept that I am under a duty to notify the Registrar if there is any change in the circumstances relating to the fitness to practise declaration that I have made within 7 days starting on the day on which the event occurred. I understand that 7.6 If I am found to have given false or misleading information in connection with my application for registration in the Register, this may be treated as misconduct, which may result in my removal from the Register. Signature Date Data Protection Statement The GPhC is a data controller registered with the Information Commissioner s Office. The GPhC makes use of personal data to support its work as the regulatory body for pharmacists, pharmacy technicians and retail pharmacy premises in Great Britain. Data may be shared with third parties in pursuance of the GPhC's statutory aims, objectives, powers and responsibilities under the Pharmacy Order 2010, the rules made under the Order and other legislation. Personal data may be processed for purposes including (but not limited to) updating the register, administering and maintaining registration, processing complaints, compiling statistics and keeping stakeholders updated with information about the GPhC. Information may be passed to organisations with a legitimate interest including universities and research institutions. Please note that the GPhC will not share your personal data on a commercial basis with any third party.

26 8A. Declaration by countersigning pharmacist or pharmacy technician This section must be completed by a practising pharmacist or pharmacy technician with current UK registration who is in good standing, after they have checked your application thoroughly and after you have signed section 7 of the application form. I declare that: 8.1 I am on the GPhC/PSNI Register 8.2 I am in good standing with the GPhC/PSNI 8.3 I have checked the documents to be submitted and confirm that they are all present and have been enclosed with this application form 8.4 To the best of my knowledge the information given in this application and in any supporting documents is true, complete and accurate and relates to the applicant. 8.5 I know of no reason why this applicant should not be registered as a pharmacy technician Name (Please print) Registration number Signature Date

27 8B. Declaration by supervising pharmacist This section must be completed if application submitted prior to completion of the 2 years relevant work based experience. I declare that: 8.6 I am on the GPhC/PSNI Register 8.7 I am in good standing with the GPhC/PSNI 8.8 The applicant will have complete the relevant period of work experience by: (Insert date below as dd/mm/yy) / / 8.9 To the best of my knowledge the information given above is true and accurate and relates to the applicant Should I become aware of any changes to the fitness to practi se declaration completed by the applicant I will notify the GPhC within 7 days of becoming so aware and advise the applicant to do likewise. I am aware of my professional obligations to do so. Name (Please print) Registration number Signature Date

28 9. Photograph certification This section must be completed by the person who signs the back of the photograph 9.1 Name 9.2 Address 9.3 Country 9.4 Occupation 9.5 Phone 9.6 address By countersigning this application, you agree that the General Pharmaceutical Council (GPhC) may contact you to verify the information that you have provided. I declare that I have signed the photograph enclosed and that I have known For years and the information I have provided is correct Please insert no. of years above *Please ensure that the date and signature on the back of the photograph matches the date and signature on this section of the application form. I certify this is a true likeness of Give applicants full name and title Signature of certifying person and date certified Staple certified photograph here Signature Date

29 10. Equality monitoring 10.1 What is you ethnic group? Please tick one White British Irish Other Black or Black British Caribbean African Other Mixed White and Black Caribbean White and Black African White and Asian Other Mixed (please specify) Asian or Asian British Indian Pakistani Bangladeshi Other Asian (please specify) Other ethnic group If other please specify 10.2 What is you gender? Please tick one Male Female 10.3 What is your sexual orientation? Please tick one Heterosexual Lesbian / Gay Bisexual 10.4 What is your religion? Please tick one None Christian Buddhist Hindu Jewish Muslim Sikh Other If other, please specify 10.5 Do you consider that you have a disability? Please tick one Yes No

30 11. Payment for application for registration as a pharmacy technician 11.1 Name of applicant Charge this card with the sum of (payment by credit card will incur a surcharge of 2%): Application Fee: Debit card: 102 Credit card ( credit card surcharge): First Entry Fee: Debit card: 108 (First Entry Fee) Credit card ( 108 First Entry Fee credit card surcharge): Please indicate whether you are paying by: Debit card Credit card Type of card Please tick one: Mastercard Visa Visa Purchasing Visa Delta Maestro Solo Card number (insert the exact amount of digits in your card number only) CSC number (The last 3 digits on the back of the card) Valid From Date Expiry Date Issue number Issue number for Maestro or Solo cards only. If your card does not have an issue number please enter NA in the boxes. Name of cardholder # Address of cardholder The name exactly as it appears on the debit or credit card Postcode Signature To be signed by the cardholder Date (dd/mm/yy) GPhC

31 You need to submit both the relevant application fee and the first entry fee with your application. The application fee is taken when we receive your application, the first entry fee when your name is entered onto the Register. The first entry fee covers the costs of maintaining your name on the register of pharmacy technicians for twelve months from the date of first entry. Please note Fees are non-refundable. The GPhC will not accept cheque payments An additional 47 administration fee will be levied in the event of an application for registration having to be returned to the applicant more than once. GPhC

32 STATUTORY DECLARATION Instructions for completing the appropriate declaration(s) You must complete whichever declaration(s) on this page of the form is/are applicable to your situation and the To be completed by the applicant section. The appropriate declaration(s) on this form must be completed by the applicant in the presence of a solicitor, who should then complete the Declaration by solicitor. DECLARATION A - Inability to provide a birth certificate OR birth certificate not written in English This declaration must be completed if you are unable to provide the GPhC with a copy of your birth certificate or if your birth certificate is not written in English. Please note: To be acceptable your birth certificate must state your full legal name, date and place of birth and indicate that your birth was registered within 12 months of the date of birth. DECLARATION B - Using a name other than that on birth certificate This declaration must be completed when you have changed your name to a different one from that on your birth certificate or the order in which your names appear on your birth certificate is different from that on your Application for Registration. Please note that the GPhC requires you to be registered in your full name so for registration purposes you cannot drop a name which is present on your birth certificate UNLESS you complete this declaration. DECLARATION C - If name(s) on supporting documents differ from Application for Registration All the names on your supporting documents must be identical to the names on your Application for Registration and birth certificate or marriage certificate (if applicable). If they are not identical, you must complete this declaration. PLEASE NOTE - You may need to complete more than one declaration. Declaration A Inability to provide birth certificate OR birth certificate not written in English I, of (Insert full name this must be identical to that on your application for registration) (Insert home address) do solemnly and sincerely declare to the best of my knowledge and belief, that at my birth I was given the name (Insert your name at the time of your birth) On / / in / (Insert date of birth DD/MM/YY) (Insert town / country)) and that I am unable to obtain a certified copy of my birth certificate, my birth certificate is not written in English or my birth was not registered within 12 months of the date of birth. GPhC

33 Declaration B Using a name other than that on birth certificate I, (Insert full name as written on birth certificate) Of (Insert home address) do solemnly and sincerely declare that since / / I have used and in future will be known by the name of (Insert full name you are now using this name must be identical to that on your application for registration) Declaration C If there is a variation in name between documents I, (Insert full name as written on birth certificate or if no birth certificate, use the name as provided in declaration A) of (Insert home address) declare that all documents submitted with my application for registration including the copy of the qualification certificate relate to me and that all versions of my name relate to one and the same person. To be completed by the applicant I (Insert full name you are now using this name must be identical to that on your application for registration) make the declaration(s) overleaf conscientiously believing the same to be true and by virtue of the provisions of the Statutory Declarations Act, Signed Date / / Declaration by solicitor Declared at (Insert full name and address of solicitor s premises)* This day of before me Signed (Insert solicitor s stamp here) GPhC