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ProPharmace Online Tutor Training Programme Application form
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* Indicates required question
Email
*
Your email
Personal Details
Title
*
Mr
Mrs
Miss
Ms
Please Select
Mr
Mrs
Miss
Ms
Please Select
First Name
*
Your answer
Surname
*
Your answer
Email Address
*
Your answer
Telephone Number
*
Your answer
GPhC Number
*
Your answer
How many years have you been a Pre-registration tutor?
*
None
1
2
3
4
5+
Please Select
None
1
2
3
4
5+
Please Select
Pharmacy Details
Name of Pharmacy
*
Your answer
Pharmacy Address
*
Your answer
Pharmacy Email Address
*
Your answer
Pharmacy Telephone number
*
Your answer
Is your pre-registration trainee currently enrolled on the ProPharmace Pre-registration training Programme?
*
Yes
No
By signing this form, you agree that you have read and accept the terms and conditions.
Terms & Conditions
*
By enrolling on this training programme I agree to:
Complete the training programme within the specified deadline
Complete the necessary evaluation forms
*Agree to pay a fee of £60 in the unlikely event of not completing the programme
Required
Tutor Signature ( Please Print Name)
*
Your answer
Date
*
MM
/
DD
/
YYYY
*Invoices will be sent to the Pharmacy Address provided in the unlikely event that you are unable to complete the programme.
A copy of your responses will be emailed to the address you provided.
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