Registration assessment application
Application form
February 2016
Version 1.0
I enclose with this form (please tick the boxes that apply):
Fee payment form (if you withdrew from your last assessment you will not have to pay again)
Satisfactory third progress report (week 39) if this is your first attempt at the assessment– this must be the original document
Declaration by a supervising pharmacist if this is either your third attempt at the registration assessment, or your second attempt if there will be more than 18 months between this attempt and your last one
Important: you must submit all the required documents by the advertised deadline date or your entry may not be processed.
Post your form to:
Pre-registration – Assessment Entry Applications
Customer Services
General Pharmaceutical Council
25 Canada Square
LONDON
E14 5LQ
Registration assessment application Page 1 of 5

Registration assessment application
Application form
February 2016
Version 1.0
You will need to bring your valid passport or driving licence to the registration assessment. Please write your name as it appears on the document you intend to bring. Write in block capitals in the boxes provided.
Your first name(s)
Your last name
This matches the name on my training record Yes No
This matches the name that I intend to register with
Your pre-registration number
Yes No
Your address (this is the address where we will send all assessment correspondence, including your results)
I confirm that I want to be entered for the (please tick one box below):
Summer 2016 assessment Autumn 2016 assessment
This sitting is my (please tick one box):
First Second Third
I have applied for adjustments for this assessment:
Yes No
Important: applications for adjustments must be sent separately
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Registration assessment application
Application form
February 2016
Version 1.0
You must read and sign the two declarations below
I have read, fully understand and agree to be bound by the regulations for the GPhC registration assessment. I declare that to the best of my knowledge all the information given on this form is true. I understand that any false statement will invalidate my entry.
Signature of candidate
I understand that I will need to bring a valid passport or driving licence to be able to sit the assessment.
Signature of candidate
I confirm that (name of trainee) meets the qualifying criteria to sit the registration assessment, in line with the registration assessment regulations.
Signed
Tutor’s full name
Date
GPhC number
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Registration assessment application
Application form
February 2016
Version 1.0
Registration assessment application Page 4 of 5

Registration assessment application
Application form
February 2016
Version 1.0
Name of applicant
Pre - registration number
Important: You do not have to pay the assessment fee if you withdrew from your last assessment sitting, and had already paid the entry fee (conditions apply).
Please tick to say whether you are paying by:
If you think this applies to you, please tick the box. You do not need to give your card details.
Debit card Credit card
Type of card
Mastercard Visa Visa Purchasing Visa Delta Maestro Solo
Card number
(Insert the exact number of digits in your card number only)
CSC number
(The last 3 digits on the back of the card)
Valid from date Expiry date Issue number
Issue number for Maestro or Solo cards only. If your card does not have an issue number please enter ‘NA’ in the boxes
Name of cardholder
The name exactly as it appears on the debit or credit card
Address of cardholder
Postcode
Date Signature
To be signed by the cardholder
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