Enrolment Form Course: Accredited Checking …

Enrolment Form course : Accredited Checking pharmacy technician course Please complete all fields, in capitals and delete where appropriate Candidate details: As a candidate you must fulfil the following criteria: Be a registered pharmacy technician (unless you work in Northern Ireland). Have worked at least 6 months in your current workplace Have demonstrated your ability to dispense accurately in your current workplace (Note should you leave your current workplace during the course , we have the right to withdraw you from the course as you may not be able to satisfy the course requirements in a different location). First name*: Last name: Title: Mr / Mrs / Miss / Ms / Dr Gender: Male / Female Email address: Date of Birth: Are you registered disabled? Yes / No Do you consider yourself to have a disability? Yes / No Do you wish to discuss any needs for additional support with a member of Buttercups staff? Yes / No Ethnicity (select ONE only): Asian or Asian British: Chinese / Bangladeshi / Indian / Pakistani / Other Asian Background Black or Black African: African / Caribbean / Other black background White: British / Irish / Other white background Mixed: White and Asian / White and black African / White and black Caribbean / Any other *This is your full legal name that will appear on your certificate.

Buttercups Training Ltd 1-2 The Courtyard, Main Street, Keyworth, Nottinghamshire, NG12 5AW 1 of 2 Enrolment Form Course: Accredited Checking Pharmacy Technician Course

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