GPhC Premises Restoration form.pdf - General Pharmaceutical ...

Restoration of
Pharmacy
Premises
Application form

OFFICE USE ONLY PCT OWN INSP PREM
1. Details of pharmacy premises to be restored
1.1 Trading Name
1.2 Has there been a change in the Trading Name
Yes
No
1.3 If ‘Yes’ – please provide former Trading Name
1.4 Address
1.5 Post code
1.6 Premises registration number
1.7 Date premises ready for inspection
1.8 Proposed opening date
This date should be at least 3 weeks before the
intended opening date.
The proposed opening date is the date the premises will
begin its registerable activities
1.9 Proposed closing date
The proposed closing date must be completed if
restoring exhibition premises
2. Body Corporate/NHS Trust making application (if applicable)
2.1 GPhC Owner number
If the Body Corporate/NHS Trust does not currently own
registered pharmacy premises please leave section 2.1 blank.
2.2 Name of body corporate/NHS trust

2.3 Address of body corporate/NHS trust
2.4 Superintendent registration number
2.5 Superintendent name
2.6 Director information – to be completed by Bodies Corporate only
Title First Names Surname (Family names) GPhC Registration Number
(if applicable)
Please continue on a separate sheet if necessary.
3. Sole traders or Partnership making application (if applicable)
3.1 Sole trader/Partner GPhC registration number
3.2 Name of sole trader/Partner
3.3 Partner GPhC registration number
3.4 Name of Partner
3.5 Sole trader’s home address/ Principal address of partnership

4. NHS contractual arrangements (if applicable)
4.1 Name of hospital, PCT, healthboard
5. Nature of business
5.1 Type of pharmacy
High Street/Community
Hospital
Exhibition
Mail Order/Internet
5.2 Has planning permission been granted for the pharmacy
Yes
No
5.3 If an internet pharmacy will be operated from the premises, please enter the website address:
The GPhC is now able to supply an Internet Pharmacy logo to authenticate your on-line pharmacy. If you
wish to make an application for this, please see separate form ‘Application for an Internet Pharmacy Logo’.
This is available on the Registration page of the GPhC’s website, www.pharmacyregulation.org .
6. Registered pharmacy services and activities
You are required to provide details of the type of activities undertaken or to be undertaken at the premises.
A. The GPhC will only register pharmacy premises if the principal activity at the premises is the retail sale or
supply of Pharmacy (P) medicines and / or Prescription Only Medicines (POMs). If it is not your intention
to carry out retail sales of Ps & POMs** and you are unable to tick Yes to either 6.1 or 6.2 your premises will
not be registered. You may tick more than one box in Section A.
6.1 For the main purpose of retail selling Pharmacy (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) prescription
which is a supply ‘corresponding to retail sale’.

B. Please indicate any ancillary activity that may be undertaken at the premises. You may tick more than one
box in Section B.
6.3 Pre-packing or assembly of medicines for the purpose of supply from your proposed registered
pharmacy or from another registered pharmacy within the same legal entity (ownership). ( e.g. breaking
down bulk containers into quantities more appropriate for use against prescriptions. These pre-packs
can be distributed to other registered pharmacy branches under the same ownership for their use
against prescriptions.)
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 unlicensed medicines or
extemporaneously prepare medicines in accordance with a prescription and/or to prepare and supply
Chemist’s nostrums for sale.)
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, hospital trust or any other
person or body who can be lawfully wholesaled to).
Yes
No
6.6 Other (please specify any other registerable activity you intend to carry out below)
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
registered pharmacy then you will be required to apply to the Medicines and Healthcare
products Regulatory Agency (MHRA) for the appropriate licence to cover these activities.
7. Contact details of Individual Making the Application
7.1 Name
7.2 Registration number (if applicable)

7.3 Position held in body corporate (if applicable)
7.4 Phone number
7.5 Email address
8. Declaration
8.1 I am a person applying for restoration of the pharmacy premises described above and I hereby declare
that I am or will be a person lawfully conducting a retail pharmacy business at the premises within the
meaning of Part 4 of the Medicines Act 1968.
8.2 The information that I have provided in this application for registration is complete, true and accurate.
8.3 I understand if the declaration is not completed to the satisfaction of the Registrar, the Registrar may
refuse to restore the premises in Part 3 of the Register.
8.4 Name
8.5 Registration number (if applicable)
8.6 Position held in body corporate (if applicable)
8.7 Signature
8.8 Date

9. Documentation to be submitted with the application
9.1 A description of the premises to which the application relates.
Please tick to confirm that a description of the premises included with application
9.2 One set of A4 size plans of the pharmacy layout - please see section 11.3 for details.
Please tick to confirm plans included with application
9.3 A completed payment form.
Please tick to confirm the payment form is included with application
9.3 If the Body Corporate (e.g. Limited Company or NHS Trust) does not currently own registered
pharmacy premises, please submit a completed application to nominate a superintendent
pharmacist. A link to this is available on the Pharmacy Premises page of the GPhC’s website
www.pharmacyregulation.org
Please tick to confirm the nomination of superintendent form is included with application
If the correct documentation is not submitted with this application and we have to return the
application more than once then a £46 administrative fee will be charged.
Please email the completed form along with a copy of your supporting document to
premises@pharmacyregulation.org, or post your completed form to: Premises Registration, The
General Pharmaceutical Council, 129 Lambeth Road, London SE1 7BT.

10. Payment Form (The fees below apply from 1 September 2011)
10.1 Registration number of Superintendent, or Sole Trader, or Partner.
10.2 Postcode of premises to be registered.
10.3 Credit or Debit Card information
Charge this card with the sum of (Payment by credit card will incur a surcharge of 2%):
To restore the pharmacy premises to the register you must pay the application fee of £102, plus the
appropriate restoration entry fee:
Please charge this card with the sum of: £ .
Debit Card: £221 (£102 application fee plus £119 Restoration Entry Fee
following Voluntary Removal)
Credit Card: £225.42 (£102 application fee plus £119 Restoration Entry Fee
following Voluntary Removal plus 2% surcharge)
Debit Card: £789 (£102 application fee plus £687 Restoration Entry Fee
following removal for Non Renewal)
Credit Card: £804.78 (£102 application fee plus £119 Restoration Entry Fee
following Voluntary Removal plus 2% surcharge)
Please indicate whether you are paying by
Debit card Credit card
Type of card Please tick one
Mastercard Visa Visa Purchasing Visa Delta Maestro Solo
Card number
(insert the exact amount
of digits in your card
number only)
CSC number
(The last 3 digits on the back of the card)
of the card)
Valid From Date / Expiry Date / Issue number
Issue number for Maestro or Solo cards only. If your card does not have an issue number please enter ‘NA’ in the boxes.
Name of cardholder
Address of cardholder
The name exactly as it appears on the debit or credit card
Postcode
Signature
To be signed by the cardholder
Date (dd/mm/yy)

10.4 BACS information
Account number 45165548 Sort code 60-60-04 Bank Nat West
When paying the restoration fee of either £ 221 or £789 by BACS you must enter the postcode of the
premises (1.5) as the BACS reference
11. Important information (please retain these pages for your records)
11.1 Restoration Process
The restoration of a pharmacy premises will take up to 3 months from receipt of a fully completed
application (including the correct fee).
Your application will be acknowledged in writing and a premises registration number will be issued.
The premises will be subject to a visit by a GPhC inspector.
Once approved, the premises will appear on the Society’s register search at
www.pharmacyregulation.org
11.2 Names of Directors – Body Corporate
If the GPhC does not hold a current list of Directors for the Body Corporate that is making the
application it will be required that a list of all Directors be submitted with this application.
11.3 Plans
The plans you submit should:
Identify the dimensions of the registered area (please indicate area in m 2 ).
Be drawn to scale.
Identify the dimensions of the dispensary (please indicate in m 2 ).
Clearly show the internal layout showing the areas in which medicinal products are intended to be
sold or supplied, assembled, prepared, dispensed or stored.
Detail the postal address of the building in which the premises is situated.
Detail any other relevant information including access points.
11.4 Change of Ownership
If you intend to transfer the ownership of the pharmacy premises in the future, the person or body
seeking ownership of the registered premises should be advised to contact the premises section of
the GPhC. The prospective owner must complete a transfer of ownership application. It is a
requirement that the application to transfer ownership must be lodged with the GPhC within 28 days
of the date of transfer. The fee payable for processing a transfer of ownership application is £75.
11.5 Extensions or alterations
If you intend to alter the registered pharmacy premises by making a change to the layout or a
physical alteration to the structure of the registered premises, you are required to advise the GPhC of
the planned change. Please submit one set of scaled plans. A new premises application is not
required.
If the planned alterations extend into an entirely new building, or where the proposed extension
does not coincide with a proportion of the registered area of the existing registered premises, then
an entirely new premises application is required. If in doubt please call the premises section for
guidance on 0203 365 3600

11.6 Death or bankruptcy
Please contact the registration section for guidance on 0203 365 3600
11.7 Registerable activities
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 registered pharmacy then you will be required to apply to the Medicines and
Healthcare products Regulatory Agency (MHRA) for the appropriate licence to cover these
activities.
11.8 Restoration of pharmacy premises applications by email
The GPhC now accepts restoration of pharmacy premises applications via email. To submit this form
via email, please complete as normal, scan and email as a PDF to premises@pharmacyregulation.org
Please submit the application and plans in one document.