EmailMe Form - UKCPA Membership Application Form

Title (Mr/Mrs/Miss/Ms/Prof/Dr) *

Name *

First Last

Correspondence Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code 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 Country / Region

Job title/Position *

Grade/Banding

Main area of work

Other (please specify)

Membership type *

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. *

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 UKCPA news, event information and other relevant information that we may need to send to you from time to time. 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

Other (please state)

What prompted you to join UKCPA (select all that apply)

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)

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 *

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.