You must have JavaScript enabled to use this form. You can use this form if you are a pharmacist or pharmacy technician registered with us to tell us about any issues which may affect your fitness to practise, including: cautions or convictions investigations or fitness to practise proceedings with other regulatory bodies issues connected with your academic or training career. You do not need to declare fixed penalty notices for offences such as speeding. Use this form for ad-hoc declarations. Do not use it as part of your annual renewal. You should renew your registration using myGPhC. If you have already declared a matter as part of your application to the register or your annual renewal, you do not need to declare it again unless something has changed. If you need to tell us about a health issue which may affect your fitness to practise, use the form on the ‘Health declarations’ page. If you are applying to join our register and have an issue which may affect your fitness to practise, contact our Registrations Department on info@pharmacyregulation.org. Please make sure that the information you give on this form is as accurate and detailed as possible. What you need to give us: as much detail as you can about the issue you are declaring details of your employer or training provider Are you (This is required.) A registered pharmacist or pharmacy technician? An applicant to the GPhC’s register? Registration number (This is required.) This form is for pharmacists and pharmacy technicians already on our register. If you are applying to join our register and have an issue which may affect your fitness to practise, contact our registration department on info@pharmacyregulation.org or 020 3713 8000. Type of declaration What are you declaring? (This is required.) fitness to practise or disciplinary proceedings from another body issues connected with your academic or training career a caution or conviction health matters none of these Health matters should be declared on our health declarations form This form is for declaring fitness to practise matters or cautions and convictions only. If you have another matter which you think you might need to declare, contact our Registrations department on info@pharmacyregulation.org or 020 3713 8000. Your Details Name (This is required.) Address (This is required.) Email address (This is required.) How would you like us to contact you? (This is required.) Mobile Land-line phone Email Post Help What is the best way for us to get in touch with you? Mobile number Land-line phone number Is there a time of day which is best to contact you? Help Please let us know when it would be best for you. For example, ‘before 10am’, ‘after 5pm’ or ‘not on Tuesdays or Wednesdays’. Do you have any specific communication needs? (This is required.) Yes No Please give details Help Include details of anything we might be able to do that will make it easier for you to talk to us. We will consider all reasonable suggestions. Employer or training provider details Are you currently employed or in training? Yes No Please give us the contact details of your employer or training provider. Name (This is required.) Help If you can, please give us the name of your line manager, or another appropriate person, and their direct contact details. Address Phone Email Do you consider yourself to be disabled (This is required.) Yes No Please give details of any help you need in your workplace because of your disability, and whether any reasonable adjustment has been or could be made Fitness to practise proceedings Do you have any pending or completed fitness to practise proceedings to declare? This includes issues connected to your academic or training career which led to a sanction, suspension or dismissal Yes No Help Please let us know about any fitness to practise proceedings, even if they are not yet completed or no action was taken when a final decision was made. The GPhC may have to investigate the issue separately even if no action was taken by another body. The name of the regulator, licensing body, school of pharmacy or employer involved Details of the findings or matters alleged against you Any other information about the findings or allegations you want the GPhC to know about Have these proceedings been completed? Yes No The date on which the proceedings were completed Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year19981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Year Help This might be the date you were sent a notice of decision, or the date of a hearing, for example. The date on which you were told that the matter would be referred for further consideration or a hearing Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year2022202320242025202620272028 Year Help This might be a future hearing date or deadline for a decision to be made. Giving us this information will help us know when to expect the outcome of any fitness to proceedings. Criminal proceedings Do you have a police caution, conviction, or other criminal proceedings to declare? (This is required.) Yes No Are you included in a barred list? Yes No Help Please see the Disclosure and Barring Service for more information. Have you received one of the following Caution Conviction Bindover Conditional discharge A penalty under s.115A of the Social Security Admin Act A fixed penalty, admonition or absolute discharge (Scotland) Other Please give the address of the police station where you received the caution or were charged with the offence Help This information should be on the paperwork given to you at the police station. Please give the name of the police officer who issued the caution, or the name of the charging officer, if you know it. Help This information should be on the paperwork given to you at the police station. Please give the details of the court at which you received the conviction, bindover or conditional discharge, etc. Name Help For example, Uxbridge Magistrates Court. Address Date caution/conviction etc. received Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year20212022202320242025 Year Please give a detailed description of the circumstances of the offence. Help This should include the time of the offence, where it happened, your relationship to the people involved (if any) and any mitigating factors. If there is any other information about the offence that you would like the GPhC to know about, please give details. Help This may include any steps you have taken to rehabilitate yourself after the offence or any insight you have into the nature of the offence. Leave this field blank Next Page >
