Registration

Customer Ref:

Schedule

Service/Schedule:

Termination:

Until further notice

Payment Information

Payment Day:

2021

First Payment Date:

01 May 2021

I wish to pay a regular Direct Debit of:

£60.00

Personal Details

Title

First name

Surname

Date of birth

Line1

Line2

Line3

Line4

Post code

Home phone number

Mobile phone number

Work phone number

Additional Information


01. Which Pharmacy sector do you work in?:
02. If other, please specify:
03. Organisation name:
04. General Pharmaceutical Council Pharmacy Technician Registration Number:
05. How did you hear about APTUK:
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?:
08. If there is not a branch near you, would you be interested in assisting in setting one up?:
09. Please provide an alternative email address, incase work email is blocked:
10. Email type:

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.