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 ChristchurchCPR Skills (Level 2) for Pharmacist Assistance/Admin Christchurch

Please select a date* ---14th March 2019, 6pm-10pm, The Garden Hotel & Restaurant15th March 2019, 6pm-10pm, The Garden Hotel & Restaurant16th March 2019, 9am-1pm, The Garden Hotel & Restaurant

.

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 = ?