Locum Form

Date* (of form submission)
Locum Name*
Reg Number*
Contact Details
Address*
N.I Number*
Phone Number*
Email
Branch and Hours worked
Branch Worked*
Date Worked	Hours Worked	Hourly Rate (£)	Travel Expenses	Subtotal
Payment Details
Bank Name*
Name on Account*
Account Number*
Sort Code*
Declaration*
Signed *
I (the above named person) confirm that I am a registered pharmacist in the UK and have performed my duties as a pharmacist in accordance to the specified Pharmacies Standard Operating Procedures. Any Taxes or National Insurance payments required for the above income will be paid independently by myslef (the above named person)
* Mandatory Fields

Contact Details