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 *
Work email address. Important notice: If you include a personal email address here, we regret that your application will not be accepted. *
This MUST be your workplace email address.
Personal email address *
GPhC or other professional regulatory body registration number *
We require your registration number to confirm you are a healthcare professional.
Date of GPhC Registration
DD / MM / YYYY
Place of work *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
If you work in a hospital, please include the full name of the Trust here
Job title *
Member Type *
Qualified Pharmacist
Pharmacy Technician
Other Health Professional
International
Trainee Pharmacist
Undergraduate Student
Sector *
NHS / HSC
University
Community Pharmacy
Private Health Provider
Pharmaceutical Company
Other
Please select your primary sector only
Workplace *
Hospital
CCG
GP Surgery
Other
Please select your primary workplace only
Membership level *
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/

From 31 March 2020 we no longer issue invoices for individual membership subscriptions. Purchase orders received or dated after this date will not be accepted.

The UKCPA is no longer able to accept postal orders or cheques.
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 complimentary or discounted membership applications):
I understand that once qualified, my complimentary membership will revert to that of a qualified pharmacist member at the prevailing membership fee.
I understand that after my initial discounted year of membership as a newly qualified pharmacist, the full membership fee will be applicable thereafter at the prevailing membership rate.
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.