Are you registered disabled? Yes / No. Do you wish to discuss any needs for additional support with a member of Buttercups staff? Yes / No.

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Buttercups Training Enrolment Form Course: Preregistration Pharmacist Distance Learning Programme 2016-17 Please complete all fields, in capitals and delete where appropriate.

1 Buttercups Training Enrolment Form Course: Preregistration Pharmacist Distance Learning Programme Please complete all fields, in capitals and delete where appropriate. Trainee details: First Name: Title: Mr / Mrs / Miss / Ms Last Name: Gender: Male / Female address: Date of Birth: Are you registered disabled? Yes / No Do you consider yourself to have a disability? Yes / No Do you wish to discuss any needs for additional support with a member of Buttercups staff? Yes / No Ethnicity (select ONE only): Asian or Asian British: Chinese / Bangladeshi / Indian / Pakistani / Other Asian Background Black or Black African: African / Caribbean / Other black background White: British / Irish / Other white background Mixed: White and Asian / White and black African / White and black Caribbean / Any other Company details: Company name: Company address: Post code: Tel: address: Fax: Working hours: Invoice address if different from above: Company name: Invoicing address: Post code: Tel: Fax:

2 Data protection consent: Under UK and European Data Protection legislation, data from which living individuals can be identified are classed as 'personal data'. The handling of personal data has to comply with legal requirements covering such things as the way in which this information is acquired, how it is processed and the extent to which it is disclosed or transferred to others. Buttercups Training needs to store data about you and your course progress. The data you provide on this form will be used by Buttercups Training for administrative and statistical purposes. By submitting your personal data you are giving your consent for it to be used for these purposes. It will be used in accordance with the relevant legislation, including the Data Protection Act If you have any questions about the use of the data collected here or other personal information, please contact Buttercups Training on Please fill in this form and return it to Buttercups Training to consent to us storing your data electronically. I hereby give my consent to the storage of personal information about me and my course progress. I understand that this information may remain available and in storage after I have finished my course of study. Name of Candidate: Signature of Candidate: Date: Order Form: Topic Title Style Cost Tick to Enrol BNF & BNFC Chapter 2 A mixture of short answer questions and case studies. 45 per chapter BNF & BNFC Quizzes Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapters 11&12 Chapter 13 Chapter 14 Chapter 15 Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 11& 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 These are only available as a PDF and should be downloaded & then submitted to Buttercups for marking and feedback. 10 Exam style questions per chapter. The mark will be available immediately if the online option is chosen and trainees can contact Buttercups for advice regarding questions answered incorrectly. 9 per chapter if completed online or 13 if a downloadable PDF file is preferred. Where the PDF version is selected trainees will need to their answers to Buttercups for marking. Online PDF

3 Topic Title Style Price Tick to Enrol Responding to Symptoms Women s Health and Childhood Ailments Comprehensive set of short answer questions and case studies to download & complete. This set of materials should be submitted to Buttercups for marking and feedback. 65 POM to P Reclassifications 20 online MCQs The mark will be available immediately if the online option is chosen and trainees can contact Buttercups for advice regarding questions answered incorrectly. 20 if completed online or 26 if a downloadable PDF file is preferred. Where the PDF version is selected trainees will need to their answers to Buttercups for marking. Please indicate if you prefer online assessment or the PDF below. Topic Title Style Online PDF Calculations Paper 1 10 New Style questions Paper 2 10 New Style questions Paper 3 20 New Style questions Paper 4 20 New Style questions Drug Tariff Short answer questions, power point presentation, information booklet with further questions This should be submitted to Buttercups for marking and feedback. 65 Law and Ethics MCQs (57 questions), Responsible Pharmacist short answer questions, plus 4 case studies to discuss with your Pre-reg Tutor. The answers to the MCQs & the Responsible Pharmacist questions need submitting for marking. 66

4 Packages: The packages below will include the PDF version of the materials where both the PDF and an online assessment are available. Package Materials 4 Calculations Papers 15 BNF/BNFC Quizzes Law and Ethics Materials (as listed above) Package 1 materials plus: Women's Health and Childhood Ailments Drug Tariff Materials Package 2 materials plus: POM to P MCQs (online) BNF/BNFC Chapter questions and case studies (chapters as listed above) Package 3 plus attendance at day 7 & 8 on one of the Buttercups Programmes for the Mock exam and review. Fee 250+VAT 360+VAT 900+VAT 1140+VAT (outside of Central London or 1200+VAT in Central London)* Tick to Enrol *Venue options for mock exam option 4 are below: please indicate preferred venue Manchester A - 4 th & 5 th April 2017 Nottingham - 4 th & 5 th April 2017 Leeds A - 6 th & 7 th April 2017 Birmingham B - 18 th & 19 th April 2017 Cardiff - 18 th & 25 th April 2017 Manchester B - 25 th & 26 th April 2017 North London - 25 th & 26 th April 2017 Central London A - 8 th & 15 th May 2017 Central London B 6 th & 20 th April 2017 Birmingham A 10 th & 24 th April 2017 Leeds B 19 th & 20 th April 2017 Birmingham Late - 18 th & 19 th July 2017 All prices quoted are excluding VAT, which will be charged in addition. Please attach a cheque for the required amount to this form or contact us if you wish to pay by bank transfer.

Do you wish to apply for a shotgun certificate which will expire at the same time as your firearm certificate? Yes No

Do you wish to apply for a shotgun certificate which will expire at the same time as your firearm certificate? Yes No Page1 APPLICATION FOR THE GRANT OR RENEWAL OF A FIREARM AND/OR SHOTGUN CERTIFICATE PLEASE READ THE NOTES THAT ACCOMPANY THIS FORM CAREFULLY BEFORE COMPLETING THE APPLICATION FORM Please use black ink and