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UKCPA Membership Application Form
Membership runs for 12 months from date of application
Title (Mr/Mrs/Miss/Ms/Prof/Dr)
*
Name
*
First
Last
Correspondence Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Phone
*
Email
*
This email address will be used to register you on the UKCPA website. If it is a personal web based email address such as gmail, hotmail or yahoo, please check your junk mail for UKCPA communications.
GPhC No
Date of GPhC Registration
DD
/
MM
/
YYYY
Place of work
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Job title/Position
*
Grade/Banding
Main area of work
Hospital
Academia
Community
Industry
Student
Other (please specify)
Membership type
*
Please select
I wish to apply for full UKCPA membership
I wish to apply for student/pre reg pharmacist UKCPA membership
I wish to apply for discounted full UKCPA membership as a previous BPSA member in my pre-registration year (T&Cs apply)
I wish to apply for overseas membership
If applying for complimentary BPSA student membership or discounted membership for newly qualified ex-BPSA members, please state BPSA membership number here:
Payment options
Please note, your membership will not be activated until your subscription fee has been paid in full.
*
Please select
I will forward a signed direct debit mandate. I understand that my membership fee will be debited from my account immediately and thereafter, with due notice, on the anniversary of the month of my joining.
I will forward a cheque or postal order made payable to UKCPA
I require an invoice sending to my Trust/Employer*
I wish to pay over the phone by Debit/Credit card. I will call the UKCPA office within 7 days
I am applying for BPSA member complimentary electronic membership
I would like to pay by BACS within 7 days, please send me the UKCPA bank details
Confirmation of fees/categories can be found here: http://ukclinicalpharmacy.org/join/how-to-join/
A Direct Debit Mandate can also be downloaded from the above page.
*Please send invoice to the following address
Please note, invoices will only be sent to Trusts/Employers. The UKCPA no longer issues invoices to individuals
Please quote purchase order number:
Please tick
*
I understand that I will be sent a reminder when my membership is due for renewal
Opt in
*
I wish to receive postal and/or electronic updates, information and newsletters direct from UKCPA and the member forums
You must opt in to receive any postal or electronic mailings from UKCPA. This includes the quarterly newsletter ‘In Practice’, Award leaflets, UKCPA event flyers, conference programmes and other relevant news and literature. It also includes access/subscription to the online group forums.
Terms and Conditions (only applicable to discounted membership for previous BPSA members):
I understand that after my initial year of subscription full membership fees will be applicable thereafter and collected via annual Direct Debit.
I understand that if I do not include a completed Direct Debit mandate, confirm my old BPSA membership number or if the period between registering with the GPhC and applying to join the UKCPA exceeds 3 months, the full UKCPA fee will be payable.
I understand that my pre-registration year membership must have been immediately prior to joining the UKCPA and will be verified with the BPSA.
Please tell us how you heard about UKCPA
Please select
Recommended by a colleague
Recommended by a friend
Recommended by my manager
Recommended by my tutor
UKCPA Facebook/Twitter feed
UKCPA advertising material
Via BPSA
Via Royal Pharmaceutical Society
In a journal (eg Clinical Pharmacist)
UKCPA material displayed in my pharmacy
UKCPA website
Search engine
Other (please state)
What prompted you to join UKCPA (select all that apply)
Free/discounted joining fee
The ability to attend masterclasses, conferences and other events
The ability to access expertise and advice via online discussion fora
The ability to apply for UKCPA awards or project bursaries
The ability to become involved in and influence profession-wide issues
To be a member of a respected professional pharmacy association
To select more than one option, please hold down Ctrl when clicking your selection
Other (please state)
What benefits do you expect to gain from UKCPA membership (select all that apply)
Increased clinical knowledge
Developing my professional skills
Increased confidence in patient care and safety
Ability to network with pharmacy colleagues
Ability to become involved in and influence profession-wide issues
Peer review and publication of work via conference abstracts and/or awards
Ability to become involved in advanced pharmacy practice initiatives such as developing professional curricula and professional recognition processes
To select more than one option, please hold down Ctrl when clicking your selection
Other (please state)
Today's date
*
DD
/
MM
/
YYYY
Please tick
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I confirm I wish to apply for UKCPA membership
By ticking this box and submitting this form you are applying to be a member of the UKCPA. Any incomplete fields above will need to be rectified before your application can be processed. The UKCPA will hold the data submitted on this form for your membership purposes only.