Register with us  

Complete and return a copy of the registration form below with the following documents:

Proof of your National Insurance Number e.g. copy of NI card, payslip
A copy of your RPSGB Certificate
A copy of your passport, or driving licence and birth certificate
A copy of relevant CPPE Certificates
A copy of signed Terms & Conditions, Locum Tariff and Agency Tariff
A copy of your professional Indemnity Insurance
Complete Equal Opportunity section of form below as well as Medical Health Questionnaire.

Completed forms and certificates can be

  • Faxed to 0208 644 1215
  • Emailed to info@trllocums.co.uk
  • Posted to Trl Pharmacy Locums, 42, Glenthorne Close, Sutton, Surrey, SM3 9N

Please complete the form below:

Title
First Name
Surname
   
Profession
Speciality
Current Grade
Home Address
Post Code
Home Telephone
Work Telephone
Mobile Telephone
Email address
Date of birth
Age
Sex
Nationality
   
Professional Society Membership
 
Name of Society
Type of Membership
Registeration Number
Renewal Date
1. When did you start working as a Locum?
2. Do you have a Professional Indemnity Insurance? Yes No
3. Pharmacy Computer System Experience. Please indicate which of the Computer Systems you have used, hold CTRL to select many.

4. Indicate how many prescription items you are comfortable with?

 0-150 150-250 250-600
5. Do you require a dispenser Part-time or Full-time? Part-time Full-time
6. Can you work without a dispenser? Yes No
7. Do you need support in a busy Dispensary? Yes No
8. Will you work in a busy Dispensary? Yes No
9. Do you work weekends? Yes No
10. What is your standard minimum hourly rate? £20per hour £22per hour £25per hour Not bothered
11. Indicate your preferred working locations

London Essex Surrey Kent Wiltshire
Others please specify

12. Would you work in an independent Pharmacy not prepared to pay travel? Yes No
13. How will you prefer the Staff Level, Business Intensity, Professional Service offered by the Pharmacy? Moderate Heavy Workload Not Bothered
14. Please indicate which of these Pharmacies you have worked for?
Boots the Chemist
Tesco Pharmacy
Sainsbury Pharmacy
Asda Pharmacy
Alliance
Morrisons
Day Lewis
Rowlands Pharmacy
Lloyds Pharmacy
Co-op Pharmacy
Independent Pharmacies
15. Would you work in a Pharmacy with services including Nursing Home Dispensing? Yes No
16. Do you require One hour lunch break or half an hour (30minutes)?
17. What would be your ideal working hours? Short hours, Long hours or Other please specify
18. What working hours would you prefer?

8am-6pm
8am-5pm
9am-6pm
8pm -10pm
Others please specify

19. How far are you willing to travel? 70 miles
50 miles
55 miles
85 miles
100 miles
Others please specify
20. What is your minimum acceptable mileage rate? 25 pence per mile
28 pence per mile
45 pence per mile
Others please specify
   
Essential Services
  
21. Are you acredited in any of the following services?

Emergency Homoenal Contraception
Medicines Use Review
Repeat Dispensing
Smoking Ceasation
Minor Ailments

22. What is your availability for Locum Work Positions
From

To
23. Preferred type of assignments Short term Long term Both
24. Means of Travel? Please indicate as appropriate Car Public Transport Underground or
British Rail

25. How did you find out about TRL Pharmacy Locums?

Journals Search Engines Friends
Others please specify

   
Equal Opportunities
  
Please state your ethnic origin White Black Asian Mixed Race
Other (please specify)
Are you a British/EC National? Yes No
If the answer is NO, what entry stamp was put in your passport by immigration?
Are there any restrictions in your passport that prohibit you from working in the UK? Yes No

Are you subject to a Work Permit? (If yes, you must supply a copy)

Yes No
   
Qualifications
  
University / Institution
Date From

Date To
Course Attended
Computer System used
   
Professional Employment History
 
Current or last Employer
Address
Your Position
Start Date

End Date
Grade/Specialist
Reported to
Reasons for leaving
   
Previous Employer
Your Position
Start Date

End Date
Grade/Specialist
Reported to
Reasons for leaving
   
Two Referees
  
First Referee
  
Full Name
Job Title
Organisation
Address
Telephone / Fax
   
Second Referee
  
Full Name
Job Title
Organisation
Address
Telephone / Fax
   
Additional Information: Please add any other information you wish
   
Medical Questionnaire and Declaration of Health  
Title
First Name
Last Name
Please indicate whether you have suffered from any of the following illnesses  
Back Strain Yes No
Typhoid/Dysentery Yes No
Tuberculosis Yes No

Diabetes

Yes No
Gastro-Enteritis Yes No
Epilepsy/ Blackout Yes No
Allergies Yes No
Heart Disease Yes No
Bronchitis or Asthma Yes No
High Blood Pressure Yes No
Nervous Breakdown or mental disorder Yes No
Chest Pain and Shortness of Breath Yes No
Any Serious Accident or operation Yes No
Any Other Condition or Disability Yes No
Are you Registered Disabled Yes No
   
If you have answered yes to any of the above conditions, please give details  
llness or Condition
Year
How long were you suffering from this?
Treatment Received
Have you any physical, mental or related problems which might prejudice you undertaking an assignment? Yes No
If Yes give details
Date of last X-Ray
Results
   
Have you worked in an environment where MRSA has been diagnosed? Yes No
Vaccination Dates
Hepatitis A Yes No
Hepatitis B Yes No
Tetanus Yes No
Diphtheria Yes No
Tuberculosis Yes No
Rubella Yes No
Typhoid Yes No
BCG Yes No
Pollomyetitis Yes No
Date of Last Medical Screening
   
Have you suffered from diarrhoea, sore throat, or skin trouble within the last month? Yes No
   
We look forward to working with you. If you have any queries about the process of registering with us, please give us a call on 0208 644 1215 and we’ll be very happy to assist.
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