Email:
Sex:		Male Female
Date of Birth
PSI Registration Number
University
Qualifications		DiplomaDegreeMastersPHD
Year of Graduation		-Select Year-195019511952195319541955195619571958195919601961196219631964196519671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010
Home Phone
Mobile Phone
Home Address
Country (Please Select)		(please select a country)noneAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea Democratic People's Republic ofKorea Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia Federated States ofMoldova Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LUCIASaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan Province of ChinaTajikistanTanzania United Republic ofThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe
-------------Pharmacy Experience		-----------------
Independent Pharmacies		None Less than 1 year 1-5 years More than 5 years
Additional Comments
Multiple Pharmacy Companies		None Less than 1 year 1-5 years More than 5 years
Additional Comments
Supermarket Pharmacies		None Less than 1 year 1-5 years More than 5 years
Additional Comments
Hospitals		None Less than 1 year 1-5 years More than 5 years
Additional Comments
GP Practices		None Less than 1 year 1-5 years More than 5 years
Additional Comments
-----------------Accreditations		(Check if Applicable) -------------------
-------------------Essential Services		-------------------
Dispensing (including support for people with disabilities)
Repeating Dispensing
Disposal of unwanted medicines
Clinical Governance
----------------Advanced Services		------------------------
Medicine Use Review
Prescription interventions
-----------Enhanced Services		-------------------------
Minor Ailments
Smoking Cessation Services
Supervised administration of prescribed medication
Needle and Syringe exchange schemes
Anticoaugulant monitoring
Medicines assessment and compliance support
Care Home Support
Patient Group Direction Service
Full Clinical Medical Review
*** First Reference		***
Referee Name:
Position
Company Name
Contact Number
Email
***Second Reference		***
Referee Name
Company Name
Contact Number
Email

Confirm Registration

To complete your registration please send us a copy of your PSI certificate and a copy of passport (photo page only).

If you are newly qualified and have not yet received your certificate, please send us a copy of your society letter.

This information can either be faxed to  091 539761 , or emailed to locums@sigmar.ie or by post

Once we have received your application and accompanying documents we aim to contact you within seven working days