UKPPG Membership Application Form
| 1. | Surname | |
| 2. | Initials/first name | |
| 3. | Title (please circle or give details) | Professor Doctor Mr Mrs Ms Miss Other (please state) |
4. Academic History
| Qualification | Date of Attainment |
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5. Work Address
| Work address:
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| Telephone | |
| Fax | |
6. Areas of employment (please tick where relevant)
q NHS Psychiatric Hospital
q Private Psychiatric Hospital
q NHS General/Acute Hospital with mental health beds
q Learning Disabilities
q Community
q Advisory
q Industry
q Consultancy
q Academia
q Community Services
q Other (please state/give details)..............................
| 7. | Job title | |
| 8. | Job Grade | |
| 9. | Year of commencement of current position |
10. Special interests (please tick where relevant)
q General psychiatry
q Forensic Psychiatry
q Substance misuse
q Mother and Baby
q Learning Disabilities
q Child psychiatry
q Counselling
q Eating Disorders
q Drug Information
q Discharge Planning
q Old Age Psychiatry
q Adverse Drug Reactions
q Alcohol Abuse
q Patient Information
q Others (please give details)
11. Are you taking the postgraduate qualifications in psychiatric Pharmacy?
q Yes q No
12. Are you an MSc or postgraduate Diploma Psychiatric Pharmacy student?
q Yes q No
13. Are you a Regional or local tutor for the Certificate/Diploma/MSc?
q Regional q Local q Not applicable
14. Did you attend the last UKPPG Annual Conference?
q Yes q No
15. I, the undersigned, wish to apply for membership of the United Kingdom Psychiatric Pharmacy Group. In doing so, I agree to the personal information detailed above, which to the best of my knowledge is a true and accurate representation of fact, being held on the current membership database. I understand that this information is private and confidential and will only be released by express permission of, and through, the authorised committee.
Signature ………………………………………………………………………………… Date ………………………………
The joining fee is £30, which includes the first year's retention fee of £10. This is repayable if membership lapses beyond the second year. An annual retention fee of £10 is then payable on the anniversary of first joining for which a standing order facility is available.
Please print off this application form, fill it in and forward the completed application form and payment (cheques payable to "United Kingdom Psychiatric Pharmacy Group") to:
Michael Marven, Chief Pharmacist, Oxfordshire and Buckinghamshire Mental Health NHS Trusts, Clinical Pharmacy Support Unit, Unit 46, Sandford Lane Business Park, Kennington, Oxford OX1 5RW, Tel 01865 455713, Fax 01865 455720