Customer Ref:
Schedule
Service/Schedule:
New Members - 1. Full Membership
Termination:
Until further notice
Payment Information
Payment Day:
1
15
January
February
March
April
May
June
July
August
September
October
November
December
2021
First Payment Date:
01 May 2021
I wish to pay a regular Direct Debit of:
£60.00
Personal Details
Title
---Select---
Mrs
Mr
Miss
Ms
Dr
Sir
Lord
Lady
Prof.
Rev.
Master
Mx
First name
Surname
Date of birth
Line1
Line2
Line3
Line4
Post code
Home phone number
Mobile phone number
Work phone number
Email
Additional Information
01. Which Pharmacy sector do you work in?:
---Select---
CCG
Community
Education
Hospital
Industry
MOD
Other
Prison
Private
02. If other, please specify:
03. Organisation name:
04. General Pharmaceutical Council Pharmacy Technician Registration Number:
05. How did you hear about APTUK:
---Select---
APTUK Conference
APTUK Website
Pharmacy Show
Clinical Pharmacy Congress
Friend
Colleague
Current APTUK Member
06. If you have been referred by an existing APTUK member, please enter their name:
07. Would you be interested in joining an APTUK branch?:
---Select---
Yes
No
Maybe
08. If there is not a branch near you, would you be interested in assisting in setting one up?:
---Select---
Yes
No
Maybe
09. Please provide an alternative email address, incase work email is blocked:
10. Email type:
---Select---
Plain Text
HTML
Instruction to your Bank or Building Society to pay by Direct Debit
Eazy Collect Re www.aptuk.org, One Victoria Square, Birmingham, B1 1BD
Service User Number:
Account holder name
Account number
Bank sort code
Please tick to confirm you are the only person required to sign for this account
Checking the box indicates that I am the Bank/Building Society holder and no authority other than my own is required. If more than one person is required to authorise debits from the account, you are unable to setup a direct debit online.
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