BPA Application Form

Select Role

Please select role

Title

Please select Title

First Name(s)

Please enter your first name

Surname

Please enter your Surname

ADDRESS

First Line

Please Enter Address First Line

Second Line

Please Enter Address Second Line

Town/City

Please enter town/city

County

Please enter county

Postcode

Please enter postcode

Country

Please select Country

Home Phone Number

Please enter Home Phone Number

Mobile Number

Please enter Mobile Number

E-mail

Please enter email

GPhC reg

Please enter GPhC reg

RPS reg no

Please enter RPS reg no

Boots staff no

Please enter Boots staff

Please complete the section below to allow payroll to deduct your subscription directly from your salary.

ADVICE TO PAYROLL

Please debit from my monthly salary the sum of £8.00 (Eight Pounds) from today for the credit of the Boots Pharmacists’ Association and make similar payments MONTHLY from my salary THEREAFTER until I cancel this order in writing to the CEO, BPA (3 months notice will be required).

Your First Name

Please enter Your First Name

Your Surname

Please enter Your Surname

Boots Staff no

Please enter Boots Staff no

Date (dd/mm/yyyy)

Please enter Date

If you have been referred to BPA by an existing member, please enter their details in the three boxes immediately below:

Staff No

Please enter Staff No