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Membership Renewal Declaration
To ensure that the information that we hold relating to your business is up to date please ensure that this mandatory renewal declaration is completed.
* Denotes a mandatory field
*
NPA Membership number:
(Required.)
*
Your premises address:
(Required.)
Trading name:
Address line 1:
Address line 2:
Town/City:
County:
Postcode:
Tel. Number:
Email Address:
Fax:
Trading name:
Address line 1:
Address line 2:
Town/City:
County:
Postcode:
Tel. Number:
Email:
Fax:
Website:
No. of years trading at this address:
Superintendent Pharmacists name:
Superintendent Pharmacist email address:
Number of staff at this address
*
Full time
(Required.)
Pharmacist
Locum
Technician
Dispensary Assistant
Counter Assistant
*
Part time
(Required.)
Pharmacist
Locum
Technician
Dispensary Assistant
Counter Assistant
*
General:
(Required.)
Total payroll (Gross) (£):
Annual Turnover (£):
Average number of prescriptions dispensed each month:
Approximate internal square footage of the premises (sq ft):
Approximate internal square metres of the premises (sq mtrs):
How many consultation rooms do you have?
*
Do the premises operate under a 100 hour Pharmacy Contract
(Required.)
Yes
No
*
Are you registered as an internet/mail order/distance selling pharmacy with the professional regulator?
(Required.)
Yes
No
*
Do you undertake any of the following activities:
(Required.)
Yes
No
Internet/Mail Order pharmacy services:
Yes
No
Internet/Mail Order non pharmacy services:
Yes
No
Non Cosmetic Nail Care:
Yes
No
Independent Prescribing:
Yes
No
Phlebotomy:
Yes
No
Number of staff, names and job titles of the individuals conducting the activities.
Number of Staff:
Non Cosmetic Nail Care:
Independent Prescribing:
Phlebotomy:
Name(s):
Non Cosmetic Nail Care:
Independent Prescribing:
Phlebotomy:
Job Title(s):
Non Cosmetic Nail Care:
Independent Prescribing:
Phlebotomy:
Wholesaling:
Yes
No
If your wholesaling activity is more than 5% of your turnover figure what % of turnover is in respect of wholesaling:
What is your wholesaling registration number:
