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* ---10 February 2020 - North Shore Hospital, Shea terrace Entrance, Whenua Pupuke14 February 2020 - North Shore Hospital, Shea terrace Entrance, Whenua Pupuke18 February 2020 - Green Cross Head office, 602 Great Sth Road, Ellerslie19 February 2020 - North Shore Hospital, Shea terrace Entrance, Whenua Pupuke

.

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: 10-5 = ?