Avicenna Pre-registration Training Booking Form 2019-20
ProPharmace Pre-Registration Training Programme
Email address *
Pre-Registration Trainee
Title *
Mr
Mrs
Miss
Ms
Please Selct
First Name *
Your answer
Surname *
Your answer
Personal Email Address *
Your answer
Mobile Number *
Your answer
Trainee GPhc Number
Your answer
University *
Your answer
Dietary / Mobility Requirements
Your answer
Pre-Registration Tutor
Title *
Mr
Mrs
Miss
Ms
Please Selct
First Name *
Your answer
Surname *
Your answer
Tutor Email Address *
Your answer
Avicenna ID. *
Your answer
Pharmacy Name. *
Your answer
Pharmacy Address *
Your answer
Pharmacy Postcode *
Your answer
Pharmacy Tel No. *
Your answer
Pharmacy Email Address *
Your answer
Members who pay the Avicenna membership fee for 2019-2020 will be eligible for a £50 refund.
Booking Details
Nine Month Pre-registration Training Programme *
Required
Optional Training Days
Venue Location *
LONDON
LEICESTER
BIRMINGHAM
MANCHESTER
LEEDS
PORTSMOUTH
Please Select
By signing this document, you agree that you have read and accepted the terms and conditions
Tutor Signature ( Please Print Name) *
Your answer
Trainee Signature ( Please Print Name) *
Your answer
Date *
MM
/
DD
/
YYYY
Terms & Conditions *
Required
1.1 Registration Policy
All trainees registering on the training programmes will be required to complete
and sign an application form in order to apply for a place on the training programme.

1.2 Payment Policy
Placements are available on a first come first served basis.
All bookings are secured once payment has been received.

1.3 Cancellation and Refund policy
Once trainees start on the training programmes we regret that no refunds can be
processed. If a delegate fails to attend an event, the full course fees are
payable/non-refundable. A full refund is provided for tutors who's trainees
fail to start training at the Pharmacy provided that ProPharmace is notified
four weeks prior to their trainees start date on the programme.
All other cancellations and requests must be made in writing to ProPharmace
either by email (info@propharmace.com) or fax on 02071128287.

1.4 Transferring Events
We are unable to accommodate requests to transfer between events once programmes are fully booked.

2 Code of Conduct
We reserve the right to dismiss delegates from training sessions if behaviour is deemed
disruptive on the training days. Trainees will be expected to sign a code of conduct
declaration on their rst training day

3. DISCLAIMER
We reserve the right to cancel an event at any time and offer an alternative date,
a credit or a refund without any liability for consequential or indirect loss.
Programmes are correct at the time of going to print. However,
alterations may occasionally be necessary. Whilst based on current accepted
practice and/or specialist knowledge, the views expressed by trainers and
speakers are their own. ProPharmace does not accept any liability for advice
given or views expressed by them to delegates.

A copy of your responses will be emailed to the address you provided.
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