Registration

ELS Locum Registration Form

Locums take a rural break…….and get paid!

Be part of a new rural emergency locum service and Pharmacy Guild initiative.

If you are a Pharmacist

If you want great pay

If you can get away for a maximum of 7 days

Then you can be an emergency rural locum.

Get to see parts of Australia you only ever dreamed of visiting and be part of a long overdue community service helping fellow pharmacists to cope when an emergency occurs

• Nothing to organise just pack your bag
• Travel and accommodation all organised and paid for
• Take a break; it’s practically an outback holiday with top pay

Just fill in the form below & return to signify your interest and we’ll ring you.

I'd like to be an ... "Emergency Rural Locum"
*First Name:
*Last Name:
Address:
State:	NSW   QLD   VIC   WA   NT   TAS   ACT   SA
Postcode:
Home Phone:
Business Phone:
Mobile Phone:
*Email:
Date of Birth:
Nominated Months Please nominate in order of preference (1,2,3...) which month or months best suit you to get away and act as an emergency locum
August 2020	1   2   3   4   5   6   7
September 2020	1   2   3   4   5   6   7
October 2020	1   2   3   4   5   6   7
November 2020	1   2   3   4   5   6   7
December 2020	1   2   3   4   5   6   7
January 2021	1   2   3   4   5   6   7
February 2021	1   2   3   4   5   6   7
Can you leave for an emergency post in 24 hours?	Yes     No     Not sure. I need more detail
QCPP Accredited	Yes     No
Registration Numbers: PHA
Do you have an ABN?	Yes     No
Curriculum Vitae
Please attach a copy of your current CV: (We only accept MS Word and Adobe PDF documents, max file size 10MB)
Please attach a current photo: (We only accept JPEG and TIFF files)
I have read and understood the terms and conditions below.	I agree I do not agree