RECOGNITION AS AN EEA QUALIFIED PHARMACIST

INFORMATION and APPLICATION PACK

ApplicationforRecognitionasan EEAPharmacist

International Applications 129 Lambeth Road, London SE1 7BT Tel 0203 365 3550 Email: international@pharmacyregulation.org

ThankyouforyourenquiryaboutrecognitionasanEEAqualifiedpharmacistinBritain. TheGeneralPharmaceuticalCouncil(GPhC): TheGPhCisthecompetentauthorityforpharmacistsandpharmacytechniciansinGreatBritain. TheGPhCisastatutorycorporationestablishedunderthePharmacyOrder2010(Statutory Instrument2010/231) TheGPhCisgovernedbyaCouncilof14members,includingtheChair.TheCouncilhasequal numbersoflayandregistrantmemberswhoareindependentlyappointed.Anyone(includingEEA pharmacists)whowishestopracticeasapharmacistandusetherestrictedtitlepharmacistin GreatBritainmustberegisteredwiththeGPhC.

Youarerequiredtocompletethisapplicationpackifyouare:

anationalofaMemberStateoftheEuropeanEconomicArea(EEA)orareanexemptperson andingoodstandingwithyourprofessionalauthorityinyourMemberState andentitledtopractiseasapharmacistintheEEA

ThisapplicationforrecognitionwillenabletheGPhC,onceyouhaveprovidedalltherequired documentationaslisted,todetermineyourappropriateroutetoregistrationandsupplytherelevant applicationforregistrationform. ALLDOCUMENTSSHOULDBESENTTO: InternationalApplications GeneralPharmaceuticalCouncil 129LambethRoad London SE17BT Tel:02033653550 Email:international@pharmacyregulation.org

ApplicationforRecognitionasan EEAPharmacist
TheProcess EEAnationalsqualifiedaspharmacistsintheEEAshouldusethisinformationpacktomaketheir application.Tobeeligibletoapplyyoumusthavecompletedanappropriatepharmacycourseand mustberegisteredoreligibletoregisterasapharmacistinyourMemberStateofqualification. Whenwereceiveyourapplication,undernormalcircumstancesitwillbeprocessedwithin5 workingdaysofreceiptinthedepartment. Wealwaystrytoprocessapplicationsforrecognitionasquicklyaspossible.Wewillreviewyour applicationdocumentationwithinonemonthofreceiptandcontactyoubyemailifany documentationisincorrect. Pleasenotethatdocumentstatuscanchangeduringtheprocessonreceiptofnewdocuments. Oncetheapplicationisconsideredcomplete,itwillreceiveafinalcheckinpreparationfor dispatchoftheapplicationforregistrationformtoyou.

Generalinformationoncompletingtheapplication: CompletethedocumentsinblackballpointpenandinBLOCKCAPITALS(unlesslowercase isessentialsuchasinamemailaddress) Wealwaystrytoprocessapplicationsasquicklyaspossible.Whenwereceiveandprocess additionaldocumentationinthedepartmentwewillalwaysacknowledgereceiptand updateyouonthestatusofyourapplicationatthetime,usuallybyemail. Ifyouwantanacknowledgementofreceiptofyourinitialapplicationpleaseincludea stampedselfaddressedenvelopeorpostcardwithyourwithyourapplication.Thiswillbe postedonreceiptofyourapplicationintheinternationaldepartment. Tohelpusprocessyourapplicationasquicklyaspossible,pleasecheckyourdocuments verycarefullytomakesureyouhaveprovidedallthatisrequiredandintheformat required(egcertifiedcopyororiginaldocument).Werecommendthatyoumakeuseof thechecklistprovidedintheinformationpack. Ifweneedtocontactyouwewillusetheemailandpostaladdressthatyouenteronyour questionnairesoitisimportanttomakesurethesedetailsareuptodate,accurateand legible.YouMUSTadviseusofanychangeofcontactdetailsassoonaspossible.Ifyouare intheUKensureyouuseyourUKaddressonyourquestionnaire.Ifyoudonotuseyour UKpostaladdressonyourquestionnaireimportantdocumentsmaybesenttoyour addressoutsidetheUKandtherewillbeconsiderabledelayinprocessingyourapplication. Wewouldadviseyoutosendyourapplicationbysomeformofdeliverythatrequiresa signaturebytheGPhC.Pleaseensureyouaddressyourenvelope/packageto Internationalapplications. Pleasenotethateventhoughpostmayhavebeensignedintothebuilding,itdoesnot necessarilymeanthatithasbeenreceivedintheinternationaldepartment.

ApplicationforRecognitionasan EEAPharmacist
1.Names Yourdocumentsmayhavevariationsofyournames.TocompleteyourapplicationyouMUST provideofficialdocumentationorasworndeclarationasfollowstoverifyanynamechangesor variations. Marriage/CivilPartnershipcertificate StatutorydeclarationswornbeforeaUKregisteredsolicitororBritishEmbassyofficial.

2.Certifiedcopies TheGPhCrequiresacertifiedcopytobepresentedasfollows: ThedocumentMUSTbe: NBNoliquidpaperamendmentsoralterationsofanyotherkindarepermittedtocertified copies. Markedasatruecopyoftheoriginal SigneddatedandstampedbyaUKregisteredsolicitororBritishEmbassyofficial. Pleasenotethattheofficewillnotacceptcopiesthathavebeencertifiedbypersonssuchas policeofficers,localgovernmentofficialsorotherprofessionals.

NB.IfyouapplywithaUKaddressyouwillbeexpectedtoprovidedocumentscertifiedbya solicitorlicencedtopracticeintheUK. 3.Translations AnydocumentthatisnotprovidedintheEnglishlanguageMUSTbeaccompaniedbyatranslation asfollows: Thetranslationmustbecompletedbyanauthorisedtranslator Itmustbealiteraltranslation,notaninterpretationoftheoriginaldocument Allcertificationsandinkstampsontheoriginaldocumentmustalsobetranslated Thetranslatormustputtheirbusinessstamponeachdocumenttranslatedandsignand datethestatementthisisatrueandaccuratetranslationandattachthetranslationto theoriginallanguagedocumentorprovidealistofthedocumentstranslated.

4.Directdocuments TheGPhCrequiresthatcertaindocumentsaresentdirectlyfromtheissuingbody/person.If thesedocumentsareconsideredtohavebeensuppliedviayourselforanyotherthirdpartythey willberejectedandyouwillberequiredtoarrangefornewdocumentstoprovideinthecorrect manner.

ApplicationforRecognitionasan EEAPharmacist
5.Inabilitytoprovidedocuments Ingeneral,yourapplicationwillnotbeconsideredforrecognitionuntilalloftherequired documentshavebeenreceivedandconsideredacceptable.Ifyoucannotsupplyanydocuments requiredyoushouldprovideawrittenexplanationofwhythissituationhasarisen.Ifyour explanationisacceptedyouwillbeadvisedofhowtoproceedandwhatalternativedocuments maybeconsidered. 6.Dataprotection TheGPhCisadatacontrollerregisteredwiththeInformationCommissionersOffice.TheGPhC makesuseofpersonaldatatosupportitsworkastheregulatorybodyforpharmacists,pharmacy techniciansandretailpharmacypremisesinGreatBritain.Datamaybesharedwiththirdparties inpursuanceoftheGPhCsstatutoryaims,objectives,powersandresponsibilitiesunderthe PharmacyOrder2010,therulesmadeundertheOrderandotherlegislation.Personaldatamay beprocessedforpurposesincluding(butnotlimitedto)updatingtheregister,administeringand maintainingregistration,processingcomplaints,compilingstatisticsandkeepingstakeholders updatedwithinformationabouttheGPhC.PleasenotethattheGPhCwillnotshareyour personaldataonacommercialbasiswithanythirdparty. 7.TheGPhCreservestherighttorequestadditionaldocumentsatanytimeduringthe applicationprocess.

ApplicationforRecognitionasan EEAPharmacist
Documentsrequiredfromtheapplicant: 1.Fees Pleasenoteyourapplicationwillbereturnedtoyouimmediatelyonreceiptifyoudonot includethescrutinyfeewithyourinitialapplication. Scrutinyfee103tobepaidwithinitialapplication Applicationforregistrationfee100tobepaidonrequestbyGPhCwithapplicationfor registrationform. Firstentryfee262tobepaidonrequestbyGPhCwithapplicationforregistrationform. Thisisthefeeforyournametobeontheregister(providingyouremainingoodstanding) for12monthsfromthedateyoufirstjointheregister Pleasenotethatfeesarereviewedannually.

PaymentofFees: Youshouldpaythefeesbycreditordebitcardusingthepaymentformsprovidedtoyou.Youmay useacardthatisnotinyournameprovidingyouhavethepermissionofthecardholdertouseit. 2.Completedquestionnaire Pleaseensureyou: 3.Diploma/DegreeCertificate Youmustprovideacertifiedcopyofyourdiploma/degreecertificate.Ifyourcertificatehasnot beenissuedbythetimeofyourapplicationforrecognition,youmustprovideanoriginalletter fromyouruniversityconfirmingthatyouhavebeenawardedthequalificationandthatyour certificatehasnotyetbeenissuedtoyou. 4.LicencetoPractice IfyouhavealicencetopracticefromyourqualifyingMemberStateyoushouldprovideacertified copyofthatcertificate. Writeclearlyinblackink Includealegibleemailaddresswherepossible.Thiswillenhancethecommunication process ProvideaUKpostaladdresswherepossible. CompleteALLsectionsofthequestionnaire

ApplicationforRecognitionasan EEAPharmacist
5.Passport/Proofofnationality Youshouldprovideacertifiedcopyofyourpassportidentitypage(includingthephotograph). Pleasenotethatyoudonothavetoincludealltheblankpagesofyourpassportinthecopy.We needtoseetheidentificationpagesandanyvalidityextensionpage. Itmaybeacceptableforyoutoprovideacertifiedcopyofyouridentitycard.Thismustbethe identitycardthatprovesyournationalityandenablesyoutotravelbetweenMemberStates. 6.Healthdeclaration Pleaseusetheformprovidedinthispack. Thedoctormustenteryourfullnameasitappearsonyourbirth/marriagecertificate. Thedoctormustsignthedeclaration,entertheirnameinprint,providetheirregistration numberandstampthedeclarationwiththeirofficialsurgerystamp Youmustcompletethedeclarationbyapplicantsection. Anyinformationenteredontheform(includingsurgerystamps)notinEnglishmustbe translated. UnderArticle50ofDirective2005/36/ECtheHealthDeclarationmustbesubmittedwith yourapplicationwithin3monthsofthedateofthedoctorcompletingthedeclaration.

7.Birth/Marriagecertificate Youshouldprovideacertifiedcopyofyourbirthcertificatewherepossible(translatedas necessary).Ifyouarenotabletoprovideabirthcertificateyoushouldcomplete declarationAofthestatutorydeclarationenclosedwiththispack. Ifyouhavechangedyournamebymarriage(femaleapplicants)youshouldprovidea certifiedcopyofyourmarriagecertificate(translatedasnecessary).

7a.Changeofnameotherthanbymarriage IfyouhavechangedyournameotherthanbymarriageyoushouldcompletedeclarationB ofthestatutorydeclarationenclosedinthispack.

7b.Namesdifferentondocuments Yournameshouldbeexactlythesameonalldocumentsprovided.Ifyournameappears differentlytothatonyourbirthormarriagecertificateonanyofyourdocumentsyou shouldcompletedeclarationCofthestatutorydeclarationenclosedwiththispack.

ApplicationforRecognitionasan EEAPharmacist
8.Photograph Youmustsupply1recentpassportstylephotographattachedtothephotographformasfollows: Requirementsforthephotograph Thephotographmustbe: Recent(takenwithinthelastmonth) Incolour Takenagainstanoffwhite,creamorlightgreyplainbackgroundsothatyourfeaturesare clearlydistinguishableagainstthebackground Undamaged,forexample,bycreasesfrompaperclips Ofyouonyourown Insharpfocusandclear Thephotographmustalsoshow: Noshadows Youfacingforwards,lookingstraighttowardsthecamera Aneutralexpression,withyourmouthclosed(noobviousgrinning,frowningorraised eyebrows) Youreyesopenandclearlyvisible(withnosunglassesorheavilytintedglassesandnohair acrossyoureyes) Noreflectionorglareonyourglasses,andtheframesshouldnotcoveryoureyes Yourfullhead,withoutanyheadcovering,unlessitiswornforreligiousbeliefsormedical reasons Nothingcoveringyourface.Pleaseensurethatnothingcoverstheoutlineofyoureyes, noseormouth. Thecountersignatory(personwhosignsthephotograph)must: beaprofessionalperson,orapersonofstandinginthecommunity.Examplesincludea pharmacist,youruniversitylecturer,aUKregisteredsolicitororthelegalequivalentin yourMemberStateoralicensedMedicalPractitioner.Thepersonprovidingthe countersignaturemustnotberelatedtoyoubybirthormarriage.Neithershouldtheybe inapersonalrelationshipwithyounorliveatyouraddress. Haveknownyouforatleast2years Certify,signanddatethebackofthephotographwiththehandwrittenwords.Icertify thatthisisatruelikenessof(givetheapplicantsfullnameandtitle). Icertifythisisatrue likenessof Yourfullname&title Signatureofcounter signatoryandthedate. Completeandsignthesectionoverleaf,Sectiontobecompletedbycountersignatory.

ApplicationforRecognitionasan EEAPharmacist

PHOTOGRAPHCERTIFICATIONFORM
Sectiontobecompletedbycountersignatory Thissectionmustbecompletedbythepersonwhosignsthebackofthephotographwiththeir details.Theymustsignthephotographandtheformwiththeexactsamesignature Pleasecompleteinblockcapitals Firstnames: Familynames: (pleaseindicateMr/Mrs/Miss/Ms) Address: TelephoneNumber: Occupation Emailaddress: Bycountersigningthisapplication,youagreethattheSocietymaycontactyoutoverifythe informationthatyouhaveprovided. IdeclarethatIhavesignedthephotographenclosedandthatIhaveknown _____________________________________________________________ (includefullnameofapplicant) for_______yearsandthattheinformationIhaveprovidediscorrect. Signature:________________________________________________
Date:________________________ September2010

ApplicationforRecognitionasan EEAPharmacist
DocumentstobesupplieddirectlytotheGPhCfromtheissuingbody 1. EvidenceofRegistrationandGoodStanding Thismustbeanoriginaldocumentfromyourprofessionalauthoritywhichconfirmsyour registrationandgoodstandingwiththatauthority.Thisdocumentmustbesentdirecttothe GPhCbyyourprofessionalauthority.Theprofessionalauthoritymustconfirmthatyouhave notbeenthesubjectofanydisciplinaryproceedingsandthattherearenodisciplinary proceedingspendingagainstyou. Ifyouarenotregisteredwithaprofessionalauthorityyouarerequiredtoprovidealetter fromtherelevantprofessionalauthorityconfirmingthatifyouwishedtoregisterwiththat authoritythereisnothingadverseknownaboutyouwhichwouldpreventyourregistration andabilitytopractiseasapharmacistinyourMemberStateofqualificationandanuptodate clearpolicerecordfromyourMemberState.Withoutanacceptableletterofgoodstanding orclearpolicerecordyourapplicationforrecognitioncannotbecomplete. UnderArticle50ofDirective2005/36/ECyourletterofgoodstandinghasavalidityof3 months.Yourapplicationmustbesubmittedwithin3monthsofthedateofissueofyour letterofgoodstanding.Youarestronglyadvisednottodelaysendinginyourapplicationonce youhaverequestedyourletterofgoodstandingtobesent. Ifyouareregisteredwithmorethanoneprofessionalauthorityand/orhaveworkedinan additionalcountryduringthelast5years,evidenceofgoodstandingfromtherelevant authority(s)willberequired.

2.CompliancewithDirectives WerequiretheoriginaldocumentfromtheCompetentAuthoritywhichconfirmsthatyour qualificationorworkexperiencecomplieswiththerelevantEuropeanDirectives.Thiscertificate mustbesentdirecttotheGPhCbyyourCompetentAuthority. DocumentsconfirmingcompliancewithArticle23ofDirective2005/36/EC,i.e.theacquiredrights certificatehasavalidityof3months.Yourapplicationmustbesubmittedwithin3monthsofthe dateofissueofthiscertificate.Youarestronglyadvisednottodelaysendinginyourapplication onceyouhaverequestedthiscertificatetobeprovided. YoumayberequiredbytheGPhCtoprovideadditionaldocumentationtodemonstrateyour compliancewiththeDirectives.Forexample,inordertocomplywiththerequirementsintroduced byDirective2001/19/ECpharmacistswhostartedtheirqualificationinItalybefore1November 1993andcompletedthisbefore1November2003arerequiredtoprovideevidencethattheir qualificationdoesindeedcomplywiththeMinimumTrainingRequirementsofArticle44ofDirective 2005/36/EC. YourroutetoregistrationwilldependonhowtheCompetentAuthoritydescribesyourqualifications and/orexperienceinrelationtotheDirective.

ApplicationforRecognitionasan EEAPharmacist
Thereare2possiblerouteswhichareoutlinedasfollows: RouteA Youwouldbeeligibletoapplyforregistrationviathisrouteifyoueither HoldaqualificationinpharmacyfromaMemberStateoftheEEAwhichislistedinAnnexV,section 5.6.2ofDirective2005/36/EC(orifnotlistedisregardedascomparabletothequalificationlistedin theAnnex)andwhichcomplieswithalltheMinimumTrainingRequirementsdescribedinArticle44 ofDirective2005/36/EC or haveaqualificationinpharmacyfromaMemberStateoftheEEAwhichwasstartedbeforethe referencedatespecifiedintheAnnexforthatMemberStateandhaveworkedinaMemberStatein anactivityreferredtoinArticle45ofDirective2005/36/EC(whichisalsoanactivityregulatedby thatMemberState)foratleast3consecutiveyearsduringthefiveyearsprecedingtheawardofthe certificate.ThesearetheacquiredrightsprovisionsofArticle23ofDirective2005/36/EC. Onceyouhavesuppliedalltherequiredevidenceandyoureligibilitytoapplyforregistration throughrouteAisdetermined,yourapplicationwillreceiveafinalcheck.Ifeverythingisinorder youwillbesenttheapplicationforregistrationandpaymentformstocompleteandreturntothe GPhC. Youwouldneedtocompletetheapplicationformusingtheguidancenotesandreturnittothe GPhCwiththeappropriateregistrationfeeand1stentryfee.(Pleaseseefeesectionforfurther details). Oncetheapplicationformandfeearereceivedprovidingeverythingremainsinorder,yourfilewill bepassedtoRegistrationandyournamewillbeputontheRegister.Youwillthenreceive confirmationofyourregistrationbyletter.Thismaytakesometimealthoughyournamewillappear ontheGPhCliveRegisteronthewebsite(www.pharmacyregulation.org)assoonasyouare registered. PleasenotethatyoumustnotworkasapharmacistorpresentyourselftobeapharmacistinGreat BritainuntilyournameappearsontheGPhCRegister. RouteB Fees: Inadditiontothe103scrutinyfeepaidwithyourinitialapplicationyouwillberequiredtopay: 100applicationfeeforregistration 369evaluationfee OnceyourRouteBapplicationhasbeenevaluatedandyouhavesatisfactorilycompletedanyrequired adaptationtrainingyouwillberequiredtopaythefollowingfee: 262firstentryfee.Thisisthefeeforyournametobeontheregister(providingyouremainin goodstanding)for12monthsfromthedateyoufirstjointheregister Youwouldberequiredtoapplythroughthisrouteif

ApplicationforRecognitionasan EEAPharmacist
yourpharmacyqualificationfromaMemberStatewasstartedbeforethereferencedateinthe DirectiveforthatMemberStateandyouhavenotworkedfor3consecutiveyearsinthelast5years asapharmacist yourpharmacyqualificationfromaMemberStatewasstartedafterthereferencedatebutthe CompetentAuthorityhasconfirmedthatyourqualificationdoesnotcomplywiththeminimum trainingrequirementsofArticle44ofDirective2005/36/EC

Onceyouhavesuppliedalltherequiredevidenceandyoureligibilitytoapplyfor registrationthroughrouteBisdetermined,youwillbeprovidedwithanapplicationfor registrationasapharmacistthroughthenoncompliantEEArouteform,whichwillbesent toyouviatheaddressyouhaveprovided. Youwouldthenneedtocompletetheapplicationformusingtheguidancenotesandreturn ittotheGPhCwiththerelevantapplicationfee(seefeesatthebeginningofthissection). Youwouldalsoneedtoprovideallthedocumentsspecifiedintheguidancenotesthat accompanytheform. ThisprocedureenablestheGPhCtomakeacomparativeassessmentofyourpharmacy qualificationsandworkexperienceasapharmacistagainstthenationalrequirementsfor registration,ietheUKMPharmdegree,12monthspreregistrationtrainingandtheGPhC registrationassessment. Shouldanysubstantialgapsbetweenyourqualificationsandexperienceandthenational requirementsforregistrationbeidentified,youmayberequiredtocompleteaperiodof additionaleducation,trainingorexperiencebeforepassingtoRegistration.Eachapplication isassessedonacasebycasebasis. yourpharmacyqualificationwasobtainedoutsidetheEEAorSwitzerlandbutithasbeenrecognised byaMemberStateandyouhavebeenpermittedtopractiseasapharmacistinthatState.

Alldocumentsshouldbesentto: InternationalApplications GeneralPhrarmaceuticalSociety 129LambethRoad London SE17BT Tel:02033653550 Email:international@pharmacyregulation.org

GENERALPHARMACEUTICALCOUNCIL QUESTIONNAIREFORRECOGNITIONASANEEAQUALIFIEDPHARMACIST Firstnames: Familynames: (pleaseindicateMr/Mrs/Miss/Ms) Address: TelephoneNumber: DateofBirth:dd/mm/yyyy MobileNumber: Emailaddress: Universityfromwhichdegreewasobtained: Titleofdegree: Datedegreestarted:Datefinished: HaveyouregisteredwithaProfessionalAuthority:Yes No PleasearrangefortheProfessionalAuthoritytoprovideyouwithacertificateconfirmingyour registration,ifrelevant,andgoodstandingandcurrentprofessionalstatuswiththatauthority.(This includesanyotherhealthprofessionauthoritythatyoumayberegisteredwitheitherintheUKor elsewhere) Detailsofanyfulltimeexperiencesinceyoufirstacquiredtherighttopractiseasapharmacistin yourmemberstate. Datestarted Datefinished Name&Address Community/hospital/ No.ofhoursper ofpremises industry(pleasestate) weekworked Nationality HaveyoupreviouslyappliedforregistrationwiththeSociety?(Tickappropriatebox)YES NO IfYES,Statedateofapplication:______/___________________/_________ DayMonthYear Ideclarethattheinformationprovidedis,tothebestofmyknowledge,correct. Signature:________________________________________________ Date:________________________ Ifyouwishtoprovideanyadditionalinformation,pleasedosooverleaf September2010

HEALTHDECLARATIONCONFIDENTIAL
DeclarationbyaMedicalPractitioner Thisdeclarationshouldbecompletedbyeither:(i)theapplicantsusualmedicalpractitioner, or(ii)amedicalpractitionerwhohascarriedoutafullmedicalexaminationoftheapplicant. Thismustbesubmittedwithin3monthsofbeingsignedbyyouandyourdoctor. Applicant First Names:__________________________________________________________________ Applicant Family Names:_________________________________________________________________
(Pleaseinserttheapplicantsfullname.Thismustbeidenticaltotheapplicantsnameontheirbirth/ marriagecertificate). TotheRegistrar Theabovenamed: hasbeenapatientofminefor_______years________months. Or hasbeenexaminedbymeon_________(date) Delete(i)or(ii)asapplicable Iknowofnoreason,ongroundsofmentalorphysicalhealth,whyshe/heshouldnotbeableto dischargetheresponsibilitiesofaregisteredpharmacist,whichIunderstand,mayincludetakingsole chargeofacommunityorhospitalpharmacy. Signed_________________________ Date__________________ PrintedName____________________ RegistrationNumber____________________OfficialSurgeryStamp__________________

Declarationbytheapplicant Iknowofnoreason,ongroundsofmentalorphysicalhealth,whyIshouldnotbeableto dischargetheresponsibilitiesofaregisteredpharmacist,whichIunderstand,mayinclude takingsolechargeofacommunityorhospitalpharmacy. Signed______________________________Date_________________ September2010

8.Photograph Youmustsupply1recentpassportstylephotographattachedtothephotographformas follows: Requirementsforthephotograph Thephotographmustbe: Recent(takenwithinthelastmonth) Incolour Takenagainstanoffwhite,creamorlightgreyplainbackgroundsothatyourfeatures areclearlydistinguishableagainstthebackground Undamaged,forexample,bycreasesfrompaperclips Ofyouonyourown Insharpfocusandclear Thephotographmustalsoshow: Noshadows Youfacingforwards,lookingstraighttowardsthecamera Aneutralexpression,withyourmouthclosed(noobviousgrinning,frowningorraised eyebrows) Youreyesopenandclearlyvisible(withnosunglassesorheavilytintedglassesandno hairacrossyoureyes) Noreflectionorglareonyourglasses,andtheframesshouldnotcoveryoureyes Yourfullhead,withoutanyheadcovering,unlessitiswornforreligiousbeliefsor medicalreasons Nothingcoveringyourface.Pleaseensurethatnothingcoverstheoutlineofyoureyes, noseormouth. Thecountersignatory(personwhosignsthephotograph)must: beaprofessionalperson,orapersonofstandinginthecommunity.Examplesincludea pharmacist,youruniversitylecturer,aUKregisteredsolicitororthelegalequivalentin yourMemberStateoralicensedMedicalPractitioner.Thepersonprovidingthe countersignaturemustnotberelatedtoyoubybirthormarriage.Neithershouldthey beinapersonalrelationshipwithyounorliveatyouraddress. Haveknownyouforatleast2years Certify,signanddatethebackofthephotographwiththehandwrittenwords.Icertify thatthisisatruelikenessof(givetheapplicantsfullnameandtitle). Icertifythisisatrue likenessof Yourfullname&title Signatureofcounter signatoryandthedate. Completeandsignthesectionoverleaf,Sectiontobecompletedbycountersignatory.

PHOTOGRAPHCERTIFICATIONFORM
Sectiontobecompletedbycountersignatory Thissectionmustbecompletedbythepersonwhosignsthebackofthephotographwiththeir details.Theymustsignthephotographandtheformwiththeexactsamesignature Pleasecompleteinblockcapitals Firstnames: Familynames: (pleaseindicateMr/Mrs/Miss/Ms) Address: TelephoneNumber: Occupation Emailaddress: Bycountersigningthisapplication,youagreethattheSocietymaycontactyoutoverifythe informationthatyouhaveprovided. IdeclarethatIhavesignedthephotographenclosedandthatIhaveknown _____________________________________________________________ (includefullnameofapplicant) for_______yearsandthattheinformationIhaveprovidediscorrect. Signature:________________________________________________
Date:________________________ September2010

Statutorydeclaration
Refertoguidancenotesforcompletion Youmustcompletewhicheverdeclaration(s)onthissideoftheformis/areapplicablefor yoursituation. YoumustcompleteBOTHboxesontheothersideofthisform DECLARATIONAInabilitytoprovideabirthcertificate

I(InsertfullnamethisnamemustbeidenticaltothatonyourApplicationforRecognition) Firstnames__________________________________________________________ FamilyNames______________________________________________________________ Address:(inserthomeaddress) ___________________________________________________________________________ ____________________________________________________________________

DosolemnlyandsincerelydeclaretothebestofmyknowledgeandbeliefthatIwasgiventhename: atmybirth

on..at..in...
(insertdateofbirth)(insertnameoftown)(insertnameofcountry)

___________________________________________________________________________ DECLARATIONBUsinganameotherthanthatonbirthcertificate I(Insertfullname,identicaltothatgiventoyouatbirth) Firstnames__________________________________________________________ Familynames______________________________________________________________ of(inserthomeaddress) __________________________________________________________________________ __________________________________________________________________________ dosolemnlyandsincerelydeclarethatsince// (insertdate)ddmmyyyy Ihaveusedandinthefuturewillbeknownbythenameof ___________________________________________________________________
(insertfullnameyouarenowusingthisnamemustbeidenticaltothatonyourApplicationforRecognition)

PleaseseeoverleafforDeclarationC.

DECLARATIONCIfnameonanydocumentdiffersfromnameonApplicationfor Registration

I(nameasonapplicationforrecognition)
Firstnames___________________________________________________________ Familynames_________________________________________________________ of___________________________________________________________________
(inserthomeaddress)

_____________________________________________________________________ declarethatalldocumentssubmittedwithmyApplicationforRecognitionrelatetomeand thatallversionsofmynamerelatetooneandthesameperson. THISBOXTOBECOMPLETEDBYTHEAPPLICANT I(insertfullnameyouarenowusing.ThisnamemustbeidenticaltothatonyourApplicationforRecognition) Firstnames____________________________________________________________ Familynames__________________________________________________________ makethedeclaration(s)overleafconscientiouslybelievingthesametobetrueandbyvirtue oftheprovisionsoftheStatutoryDeclarationAct,1835. Signed:___________________________________________________________ Date:_____________________________________________________________ DECLARATIONBYSOLICITOR(tobecompletedbythesolicitor) Declaredat(insertfullnameandaddressofsolicitorspremises): Thisdayof20__ beforeme. IconfirmthatIamauthorisedtoadministerthisoath Signed:(insertheresolicitorsstamphere) Instructionsforcompletingtheappropriatedeclaration(s) Theappropriatedeclaration(s)onthisformmustbecompletedbytheapplicantinthe presenceofasolicitor,whoshouldthencompletetheDeclarationbysolicitor(above) DeclarationA:Unabletoprovideacceptablebirthcertificate DeclarationB:Changeofnamefromthatonbirthcertificateandnotsupportedbymarriage certificate DeclarationC:DocumentshavedifferentnamestonamesgiveninAorB.

Application for recognition as an EEA qualified pharmacist Payment Form

Name of applicant

Fee to be paid by: Type of card

Trainee Mastercard Maestro

Employer Visa JCB Visa Debit Solo Visa Purchasing

Card number

(please insert the exact amount of digits on your card)

Valid From Date

Expiry Date

Issue number

Add the 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 Please charge this card with the sum of 103.00

Signature To be signed by the card holder

Date

NB: Please contact the International Applications department if you have any problems making a payment through the above methods.

September 2010