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
2025
First Payment Date:
01 August 2025
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
---Other---
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, Ludgate House, 107-111 Fleet Street, London, EC4A 2AB
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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