RegistrationOfANew PharmacyPremises

PCT OWN

INSP PREM

Section1Detailsofpharmacypremisestoberegistered
1.1 Tradingname

1.2 Premisesaddress

1.3 Postcode

1.4 Datepremisesreadyforinspection

1.5 Proposedopeningdate 1.6 Proposedclosingdate

This date should be at least 3 weeks before theintendedopeningdate. The proposed opening date is the date the premiseswillbeginitsregisterableactivities. Theproposedclosingdatemustbecompleted ifregisteringexhibitionpremises.

Section2BodyCorporate/NHSTrustmakingapplication(ifapplicable)
2.1 GPhCOwnernumber

2.2 Nameofbodycorporate/NHStrust

2.3 Addressofbodycorporate/NHStrust

2.4 Superintendentregistrationnumber

2.5 SuperintendentName

2.6 Directorinformation IftheGPhCdoesnotholdacurrentlistofDirectorsfortheBodyCorporatethatismakingthe applicationitwillberequiredthatalistofallDirectorsbesubmittedwiththisapplication. 1

RegistrationOfANew PharmacyPremises

Section3SoletradersorPartnershipmakingapplication(ifapplicable)
3.1 SoletraderorFirstPartnerGPhCregistrationnumber

3.2 NameofsoletraderorFirstPartner

3.3 SecondPartnerGPhCregistrationnumber

3.4 NameofSecondPartner

3.5 SoletradershomeaddressorPrincipaladdressofpartnership

Section4NHScontractualarrangements(ifapplicable)
4.1 Nameofhospital,PCT,healthboard

Section5Natureofbusiness
5.1 Typeofpharmacy(tickone) HighStreet/Community Hospital Exhibition MailOrder/Internet

5.2 Hasplanningpermissionbeengrantedforthepharmacy? Yes

No

5.3 Ifaninternetpharmacywillbeoperatedfromthepremises,pleaseenterthewebsiteaddress:

The GPhC is now able to supply an Internet Pharmacy logo to authenticate your online pharmacy.Ifyouwishtomakeanapplicationforthis,pleaseseeseparateformApplicationfor an Internet Pharmacy Logo. This is available on the Registration page of the GPhCs website, www.pharmacyregulation.org.

RegistrationOfANew PharmacyPremises

Section6Registeredpharmacyservicesandactivities
Youarerequiredtoprovidedetailsofthetypeofactivitiesundertakenortobeundertakenatthe premises.

SectionA TheGPhCwillonlyregisterpharmacypremisesiftheprincipalactivityatthepremisesistheretail sale or supply of Pharmacy (P) medicines and/or Prescription Only Medicines (POMs). If it is not yourintentiontocarryoutretailsalesofPs&POMs(**)andyouareunabletotickYestoeither6.1 or6.2yourpremiseswillnotberegistered.YoumaytickmorethanoneboxinSectionA.

6.1 ForthemainpurposeofretailsellingPharmacy(P)medicines. Yes

No

6.2 For the main purpose of dispensing and supplying (licensed) medicines in accordance with a prescription. Yes

No

The retail sale of medicines also includes the supply of medicines against a (NHS or private) prescriptionwhichisasupplycorrespondingtoretailsale.

SectionB
(**)Pleaseindicateanyancillaryactivitythatmaybeundertakenatthepremises.Youmaytickmore thanoneboxinSectionB. 6.3 Prepackingorassemblyofmedicinesforthepurposeofsupplyfromyourproposedregistered pharmacyorfromanotherregisteredpharmacywithinthesamelegalentity(ownership).(e.g. breaking down bulk containers into quantities more appropriate for use against prescriptions. These prepacks can be distributed to other registered pharmacy branches under the same ownershipfortheiruseagainstprescriptions.) Yes

No

6.4 To assemble and /or prepare unlicensed medicines in accordance with the limited exemption provided by Section 10 of The Medicines Act 1968. (i.e. to obtain, dispense and supply unlicensedmedicinesorextemporaneouslypreparemedicinesinaccordancewithaprescription and/ortoprepareandsupplyChemistsnostrumsforsale.) Yes

No

6.5 To wholesale medicines to another legal entity in accordance with the limited exemption provided by Section 10 of The Medicines Act 1968. (e.g. supply stock to a doctor, dentist, hospitaltrustoranyotherpersonorbodywhocanbelawfullywholesaledto). Yes

No

6.6 Other(pleasespecifyanyotherregisterableactivityyouintendtocarryoutbelow)

If you propose to wholesale, assemble or manufacture medicines and if it is likely that these activities could constitute more than an inconsiderable part of the business of the proposed registeredpharmacythenyouwill be required to apply to the Medicines and Healthcare productsRegulatoryAgency(MHRA)fortheappropriatelicencetocovertheseactivities.

RegistrationOfANew PharmacyPremises

Section7ContactdetailsofIndividualMakingtheApplication
7.1 Name

7.2 Registrationnumber(ifapplicable)

7.3 Positionheldinbodycorporate(ifapplicable)

7.4 Worknumber MobileNumber HomeNumber

7.5 Emailaddress

Section8Submittingtheapplication
Please ensure you have fully completed the application form and submitted the correct documentationasdetailedbelow.Ifyourapplicationisincompleteormissingdocumentationit willbereturnedtoyou.Iftheapplicationisreturnedtoyoumorethanonce,afeeof46willbe applicabletoresubmityourapplication. Pleaseticktheboxtoconfirmyouhavesubmittedthefollowingdocumentation. 8.1 Adescriptionofthelayoutandactivitiesofthepremisestowhichtheapplicationrelates Submitted 8.2 OnesetofA4sizeplansofthepharmacylayoutpleaseseesection11.3fordetails. Submitted 8.3 Acompletedpaymentform. Submitted 8.4 DoestheBodyCorporate(e.g.LimitedCompanyorNHSTrust)makingthisapplicationcurrently ownregisteredpharmacypremises? If you have answered No to question 8.4, submit the Yes No documentationasdetailedin8.5

8.5 Acompletedapplicationtonominateasuperintendentpharmacist. Submitted ThisapplicationformisavailableontheGPhCswebsite,www.pharmacyregulation.org.Please gotothePharmacyPremisespage

RegistrationOfANew PharmacyPremises

Section9Declaration
9.1 IamapersonapplyingforregistrationofthepharmacypremisesdescribedaboveandIhereby declare that I am or will be a person lawfully conducting a retail pharmacy business at the premiseswithinthemeaningofPart4oftheMedicinesAct1968.

9.2 The information that I have provided in this application for registration is complete, true and accurate.

9.3 I understand that if the declaration is not completed to the satisfaction of the Registrar, the RegistrarmayrefusetoenterthepremisesinPart3oftheRegister.

9.4 Name

9.5 Registrationnumber(ifapplicable)

9.6 Positionheldinbodycorporate(ifapplicable)

9.7 Signature

9.8 Date

Pleaseemailthecompletedapplicationformalongwithacopyofyoursupportingdocumentto premises@pharmacyregulation.org, or post your completed form to: Premises Registration, TheGeneralPharmaceuticalCouncil,129LambethRoad,LondonSE17BT.

RegistrationOfANew PharmacyPremises

Section10PaymentForm
Thefeeforregisteringanewpharmacypremisesis774.Pleasenote,theregistrationfeeisnon refundable.TheGPhCdoesnotacceptpaymentbycheque. 10.1 RegistrationnumberofSuperintendent,orSoleTrader,orPartner.

10.2 Postcodeofpremisestoberegistered.

10.3 Paymenttype(pleasetick) CreditCard 10.4 FeeDetails RegistrationFee557 10.5

BACS

FirstEntryFee217

Total774

CreditorDebitCardinformation 0 0

Chargethiscardwiththesumof 7 7 4 . Typeofcard

Mastercard VisaPurchasing

Visa Maestro

VisaDelta Solo

Cardnumber

IssueDate Cardholdername

Expirydate

Issueno.

IssuenumberforMaestroorSolocardsonly.IfyourcarddoesnothaveanissuenumberpleaseenterNAintheboxes.

Thenameexactlyasitappearsonthedebitorcreditcard

Signature

Date

Tobesignedbythecardholder

10.6

BACSinformation Sortcode 606004 Bank NatWest

Accountnumber 45165548

Whenpayingthenewpremisesregistrationfeeof774byBACSyoumustenterthepostcodeof thepremises(1.3)astheBACSreference

RegistrationOfANew PharmacyPremises
Section11Importantinformation 11.1 RegistrationProcess Theregistrationofapharmacypremiseswilltakeupto3monthsfromreceiptofafully completedapplication(includingthecorrectfee). Theapplicationwillbeconfirmedinwritingandapremisesregistrationnumberwillbeissued. ThepremiseswillbesubjecttoavisitbyaGPhCinspector. Onceapproved,thepremiseswillappearontheregistersearchatwww.pharmacyregulation.org NamesofDirectorsBodyCorporate

11.2

If the GPhC does not hold a current list of Directors for the Body Corporate that is making the applicationitwillberequiredthatalistofallDirectorsbesubmittedwiththisapplication. 11.3 Plans

Theplansyousubmitshould: Identifythedimensionsoftheregisteredarea(pleaseindicateareainm2). Bedrawntoscale. Identifythedimensionsofthedispensary(pleaseindicateinm2). Clearlyshowtheinternallayoutshowingtheareasinwhichmedicinalproductsareintendedto besoldorsupplied,assembled,prepared,dispensedorstored. Detailthepostaladdressofthebuildinginwhichthepremisesissituated. Detailanyotherrelevantinformationincludingaccesspoints. 11.4 ChangeofOwnership

Ifyouintendtotransfertheownershipofthepharmacypremisesinthefuture,thepersonorbody seekingownershipoftheregisteredpremisesshouldbeadvisedtocontactthepremisessectionof the GPhC. The prospective owner must complete a transfer of ownership application. It is a requirementthattheapplicationtotransferownershipmustbelodgedwiththeGPhCwithin28days ofthedateoftransfer.Thefeepayableforprocessingatransferofownershipapplicationis75. 11.5 Extensionsoralterations Ifyouintendtoaltertheregisteredpharmacypremisesbymakingachangetothelayoutoraphysical alteration to the structure of the registered premises, you are required to advise the GPhC of the plannedchange.Pleasesubmitonesetofscaledplans.Anewpremisesapplicationisnotrequired.

If the planned alterations extend into an entirely new building, or where the proposed extension doesnotcoincidewithaproportionoftheregisteredareaoftheexistingregisteredpremises,then an entirely new premises application is required. If in doubt please call the premises section for guidanceon02033653600 11.6 Deathorbankruptcy

Pleasecontacttheregistrationsectionforguidanceon02033653600 11.7 Registerableactivities If you propose to wholesale, assemble or manufacture medicines and if it is likely that these activities could constitute more than an inconsiderable part of the business of the proposed registeredpharmacythenyouwillberequiredtoapplytotheMedicinesandHealthcareproducts RegulatoryAgency(MHRA)fortheappropriatelicencetocovertheseactivities.

PLEASERETAINTHISPAGEFORYOUROWNRECORDSDONOTRETURNWITHTHEAPPLICATION 7