Registration assessment application
Application form
April 2016
Version 2.0
Registration assessment application
Application checklist
I enclose with this form (please tick the boxes that apply):
Fee payment form (if you withdrew from your last assessment you will not have to pay
again)
Satisfactory third progress report (week 39) – must be original document (only needed if
this will be your first attempt at the assessment)
Declaration by a supervising pharmacist - only needed if:
a) This is your third attempt
b) This is your second attempt and it has been more than 18 months since your last sitting
c) More than 12 months has passed since you completed a six month period of supervised
training
Important:
you must submit all the required documents by the advertised deadline date or
your entry may not be processed.
Post your form to:
Pre-registration – Assessment Entry Applications
Customer Services
General Pharmaceutical Council
25 Canada Square
LONDON
E14 5LQ
Registration assessment application
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Registration assessment application
Application form
April 2016
Version 2.0
Registration assessment application form
You will need to bring your valid passport or driving licence to the registration assessment. Please write your
name as it appears on the document you intend to bring. Write in block capitals in the boxes provided.
Title
Mr
Mrs
Ms
Miss
Other (please state)
Your first name(s)
Your last name
This matches the name on my training record
Yes
No
(If your name does not match please submit a change of details form, which can be downloaded separately from our
website).
This matches the name that I intend to register with
Yes
No
Your pre-registration number
Address (this is the address where we will send all assessment correspondence, including your results)
Postcode
Country
Telephone number
Email address
I confirm that I want to be entered for the (please tick one box below):
Summer 2016 assessment
Registration assessment application
Autumn 2016 assessment
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Registration assessment application
Application form
April 2016
Version 2.0
This sitting is my (please tick one box):
First
Second
Third
I have applied for adjustments for this assessment:
Yes
Important:
No
applications for adjustments must be sent separately by the specified deadline.
You must read and sign the two declarations below
I have read, fully understand and agree to be bound by the regulations for the GPhC registration assessment.
I declare that to the best of my knowledge all the information given on this form is true. I understand that
any false statement will invalidate my entry.
Signature of candidate
I understand that I will need to bring a valid passport or a valid UK or European driving licence photo card,
either full or provisional to be able to sit the assessment.
Signature of candidate
If you are a first-time applicant you must get your tutor to fill in the following declaration:
I confirm that
(insert name of trainee) meets the qualifying criteria to sit the registration assessment, in line with the
registration assessment regulations.
Signed
Tutor’s full name
GPhC number
Registration assessment application
Date
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Registration assessment application
Application form
April 2016
Version 2.0
This page is for office use only
Registration assessment application
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Registration assessment application
Application form
April 2016
Version 2.0
Payment form
Name of applicant
Preregistration number
Please charge this card with:
£ 1 8 2 .
0 0
Please tick to say whether you are paying by:
Debit card
Important: You do not have to pay the
assessment fee if you withdrew from your
last assessment sitting, and had already paid
the entry fee (conditions apply).
If you think this applies to you, please tick
the box. You do not need to give your card
details.
Credit card
Type of card (Please tick one)
Mastercard
Visa
Visa Purchasing
Visa Delta
Maestro
Solo
Card number
(Insert the exact number of digits in your card number only)
CSC number
Valid from date
(The last 3 digits on the back of the card)
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
The name exactly as it appears on the debit or credit card
Address of cardholder
Postcode
Date
Signature
To be signed by the cardholder
Registration assessment application
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