Fields marked with * are required

Name

Surname*

First Name*

Contact Details & Postal Address

Street*

Suburb*

City*

Postal code*

Contact Phone Number*

Email*

Course

Course* Immediate Responder (Level 4) for Pharmacists/Vaccinators AucklandCPR Skills (Level 2) for Pharmacist Assistance/Admin Auckland

Please select a date* ---18 October 201818th February 2019, 6pm-10pm, 602 Great South Road19th February 2019, 6pm-10pm, 32 – 34 View Road20th February 2019, 6pm-10pm, 602 Great South Road21st February 2019, 6pm-10pm, 32 – 34 View Road23rd February 2019, 9am-1pm, 32 – 34 View Road

.

Payment Details

NOTE: Invoices and certificates for Green Cross Health pharmacies will be sent direct to Green Cross Health for payment and distribution.

ALL Invoices certificates for non Green Cross Health pharmacies will be emailed to the email addresses given for payment.

Full Name of Pharmacy employed at*

Pharmacy
(If 'other' please give full details below) ---UnichemLifeOther (please provide details below)

Email address of Pharmacy

Postal address of Pharmacy

Street

Suburb

City

Postal code

Human test: 1+3 = ?