Name
Date of Birth (dd/mm/yyyy)
Address
Last reset
Country --------- United Kingdom Ireland
Region --------- Dublin Carlow Cavan Clare Cork Donegal Galway Kerry Kildare Kilkenny Laois Leitrim Limerick Longford Louth Mayo Meath Monaghan Offaly Roscommon Sligo Tipperary Waterford Westmeath Wexford Wicklow
Post Code (if known) or Town/Village
Transport
How far are you willing to travel? (Miles)
Happy to travel and stay over?
Mobile Number
Email
What regular days are you available?

• Monday
• Tuesday
• Wednesday
• Thursday
• Friday
• Saturday
• Sunday

Qualifications

• Pharmacist
• ACT
• NVQ3
• NVQ2

PSI Registration number (if Applicable)
Which PMR systems you can use?

• McLernons
• Touchstore
• Helix health- Quick Script
• Helix Health- RxWeb
• Smartscript (Boots)
• Compass (Lloyds)
• PharmaSys
• Analyst Pmr

Passport
File cv
Ireland Visa (if Applicable)
Visa Expires (dd/mm/yyyy)
File qualification
Proof of Qualifications (second file)
Professional Reference: Name
Professional Reference: Designation
Professional Reference: Telephone Number
Professional Reference: Email
Safeguarding certificate
Dementia self-certification
Risk Management Certificate
Oral Health Certificate
PPS Number
Job role --------- Pharmacy Assessor Independent Prescribing Pharmacist Locum Pharmacist Locum Dispenser Technician
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