Form 5.2 PHR 4514 UNIVERSITY OF MALTA DEPARTMENT OF PHARMACY IN-SERVICE TRAINING IN A COMMUNITY PHARMACY NOTIFICATION OF CHANGE Name of Student ID Card No I wish to notify the following change in my in-service training: Change in Managing Pharmacist Request change in pharmacy Change in time/day of half day session off Others (please specify) Name of pharmacy Address Tel No Half day session a week when I will not attend Signature of Student Date To be completed by Managing Pharmacist I, confirm that I will personally be responsible to help the student during the in-service training period to follow the requirements expected. I will be responsible to ensure that the student is under the supervision of a pharmacist.* Personal address Mobile No. Email address 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. Version 8_2013