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Locum Registration

Before starting we recommend you scroll down to make sure you have all the information and files required where marked with

Title

Forenames

Surname

DOB

(yyyy-mm-dd)

Address

Home Tel

Mobile

E-mail Address

Confirm E-mail

Nationality

Gender

Male Female

RPSGB Reg No

Date of Registration

(yyyy-mm-dd)

Work Permit no

NI Number

Do you have Professional Indemnity Insurance?

yes no

Name of Insurer

Policy Number

Expiry date

(yyyy-mm-dd)

Preferred Location of work

Do you have a car?

yes no

Distance preferred to travel (Miles)

Minimum mileage rate required

Expected Hourly rate

Tick Preferred days of working

Mon Tue Wed Thur Fri Sat Sun

Tick below details of all dispensary systems experience

Mediphase Nexphase Smartscript Eclipse Proscript Link 2

NDC Compass Park Other

Attach two employment references if available (will be required before placements)

MUR Accreditation

yes no

Repeat Dispensing

yes no

Other accreditations - Please list

Attach copies of your CV & any accreditation certificates

Please tick the box if you have read and agreed
to be bound by the terms & conditions

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Website: Wotnot Web Works

Locum Supply Ltd - Registered Office: Camburgh House, 27 New Dover Road, Canterbury, Kent CT1 3DN Registered no: 6980414