Voluntary Removal Application Form

Voluntary Removal of anEntry or AnnotationSection 1 – Personal Details1.1 Registration Number1.2 Name1.3 Registered Address1.4 Postcode1.5 Date of birthSection 2 – Voluntary removal of an entry from the registerTo be completed by registrants wishing to voluntarily remove their name from the register2.1 Date you wish to be voluntarily removed from the register2.2 Are you currently a superintendent pharmacist?YesNo2.3 Name of body corporate/NHS trust2.4 Owner numberSection 3 – Voluntary removal of an annotation from the registerTo be completed by registrants wishing to voluntarily remove an annotation, but who wish to remainregistered3.1 Please tick with annotation you are applying to removeSupplementaryIndependent3.2 Date you wish your annotation to be voluntarily removed from the register3.3 Signature DateSection 4 – Reason why you wish to be removed from the register4.1 Please state the reason why you are applying for voluntary removal1

Voluntary Removal of anEntry or AnnotationSection 5 – Fitness to practise mattersBy virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and the Rehabilitation ofOffenders Act 1974 (Exclusions and Exceptions) (Scotland) Order 2003, you are exempt from theprovisions of Section 4(2) of the Rehabilitation of Offenders Act 1974. Therefore you are not entitled towithhold information about convictions which for other purposes are spent under the provisions of the Actand failure to disclose such convictions could result in disciplinary action5.1 Has a determination ever been made against you by a regulatory body in the United Kingdom responsibleunder any enactment for the regulation of a health or social care profession to the effect that your fitnessto practise as a member of a profession regulated by that body is impaired, or a determination by aregulatory body elsewhere to the same effect?YesNo5.2 Do you currently have any problems with your physical or mental health that may impair yourability to practise safely and effectively or which otherwise impairs your ability to carry out yourduties in a safe and effective manner?YesNo5.3 Have you previously been convicted or cautioned for a criminal offence in the British Islands or elsewhere(which, if committed in England, Scotland or Wales would constitute a criminal offence) or have youpreviously agreed to be bound over to keep the peace by a Magistrates’ Court in England or Wales?YesNoPlease note that Road Traffic offences in which the person committing the offence has beenoffered the option of paying a fixed penalty (e.g. certain speeding offences etc) will not be treatedas a conviction for the purposes of registration in the Register and need not be declared.5.4 Have you previously agreed to pay a penalty under section 115A of the Social SecurityAdministration Act 1992 (penalty as alternative to prosecution)?YesNo5.5 Are you currently under investigation by any regulatory body (other than the GPhC) or criminalenforcement authority (e.g. police or NHS Counter Fraud Service) in the British Islands orelsewhere?YesNo5.6 Have you previously accepted a conditional offer under section 302 of the Criminal Procedure(Scotland) Act 1995 (fixed penalty: conditional offer by procurator fiscal) or have you previouslybeen subject to an order under section 246(2) or (3) of the Criminal Procedure (Scotland) Act1995 discharging you absolutely (admonition and absolute discharge)?YesNo5.7 Have you previously been included by the Independent Safeguarding Authority (also known as theIndependent Barring Board) barred list (in England, Wales or Northern Ireland) or the children’s listor adult’s list maintained by the Scottish Ministers?YesNo5.8 If you have answered ‘yes’ to any of the above questions in Section 5, have you previously notifiedthe GPhC or RPSGB of this information?YesNo2

Voluntary Removal of anEntry or AnnotationSection 6 – DeclarationPart A – Please complete either Declaration 1, 2 or 3Declaration 1 - For registrants answering ‘No’ to questions 5.1 to 5.7 in Section 51. I am applying for voluntary removal from the Register. I have answered ‘No’ to all the Fitness toPractise questions in Section 5 and declare I am not aware of any investigation by anyenforcement or regulatory body, or proceedings brought by such a body, that relates to myfitness to practise, or of any act or omission on my part which might render me liable to anallegation being referred to the GPhC that my fitness to practise is impaired. The information Ihave provided for this application is complete, true and accurate.Please tickDeclaration 2 - For registrants answering ‘Yes’ to question 5.8 in Section 52. I am applying for voluntary removal from the Register. I have answered ‘Yes’ to one or moreFitness to Practise questions in Section 5 but I am not required to complete a Something toDeclare form as I have previously notified the RPSGB or GPhC of the matter(s). I also declarethat I am not aware of any investigation by any enforcement or regulatory body, or proceedingsbrought by such a body, that relates to my fitness to practise, or of any act or omission on mypart which might render me liable to an allegation being referred to the GPhC that my fitness topractise is impaired. The information I have provided for this application is complete, true andaccurate. If it is relevant to my application, I request that the Registrar considers my applicationfor voluntary removal from the register in accordance with Rule 14(6)(b) of the GPhCRegistration Rules 2010.Please tickDeclaration 3 - For registrants answering ‘No’ to question 5.8 in Section 5You are also required to submit a ‘something to declare’ form within 7 days of making yourdeclaration. The ‘something to declare’ form is available on our website,www.pharmacyregulation.org.3. I am applying for voluntary removal from the Register. I have answered ‘Yes’ to one or morequestions in Section 5 and understand I am required to submit a completed ‘something todeclare’ form within 7 days. I request the Registrar to consider my application for voluntaryremoval from the register in accordance with Rule 14(6)(b) of the GPhC Registration Rules 2010.Please tickPart B – Please sign and date the application6.1 Signature6.2 DateIMPORTANTIf your renewal fee is paid by staged direct debit, the remaining balance of your renewal fee must bepaid with your application for voluntary removal. Please complete the attached payment form.3