PHR 1101, 2103, 3106, 4112
Form A
UNIVERSITY OF MALTA
DEPARTMENT OF PHARMACY
NOTIFICATION OF TRAINING IN A COMMUNITY PHARMACY
Name of Student
Course year
Address
Tel No.
Mobile Phone
E-mail
ID Card No
I wish to request approval to undertake my undergraduate training at :
Name of pharmacy
Address
Tel No
Day and session when I will be attending
Signature of Student
Date
To be completed by Managing Pharmacist
I,
confirm that I will personally be
responsible to help the student during the training period. I will be
responsible to ensure that the student is under the supervision of a
pharmacist.*
Personal address
Tel No
Signature of Managing Pharmacist
Date
Registration Number
* Managing pharmacists are advised that it is considered against the ethical practice to sign
any document including attendance which are not true to the facts.