Resident Training Program – Community Pharmacy Candidate Registration Step 1 of 4 – Part 1: Resident Candidate Details 25% Resident Candidate DetailsName(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Assoc. Prof. Prefix First Last Email(Required) Mobile(Required)Year of birth(Required) Gender(Required)Please select oneFemaleMaleNon-binaryOtherState(Required)ACTNSWNTQldSATasVicWAPost code(Required) Are you an AdPha member?(Required) Yes No If Yes, what is your AdPha member number?(Required) AHPRA Registration Number(Required) Year you first obtained General Registration(Required) Date you start the Resident Training Program(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Workplace DetailsName of Community Pharmacy(Required) Name of Banner Group(Required) Name of Pharmacy Owner/Proprietor/Franchisee(Required) Nominated Preceptor DetailsPreceptor First Name(Required) Preceptor Last Name(Required) Preceptor email(Required) Preceptor mobile(Required) Please upload your proposed Preceptor's CV(Required) Drop files here or Select files Accepted file types: png, jpg, pdf, doc, docx, Max. file size: 5 MB. Consent and DeclarationResident Training Program(Required)By checking this box, you agree to participating in the Resident Training Program delivered by your pharmacy and in accordance with AdPha’s requirements as outlined in the AdPha Community Pharmacy Resident Training Program Framework. I agreePrivacy Policy(Required)You agree to the AdPha privacy policy available at https://www.adpha.au/privacy-policy I agreeDeclaration(Required)By checking this box, you declare that the information you have provided is true and correct and in no way misleading. I agreePhoneThis field is for validation purposes and should be left unchanged.
