Chapter 12A Annex 1 Application Form Application in respect of a consolidation onto an existing site Application in respect of a consolidation onto an existing site in the area of: .…………………………………………… (insert name of health and well-being board). A consolidation application must be in relation to pharmacy premises that are located within the area of a single health and wellbeing board. This is an application in respect of a consolidation onto an existing site and as such is an excepted application under regulation 26A(1) of the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 (the "Regulations"). Please complete this form as legibly as possible. Applicants should note that information provided in this form may be disclosed where this application is required to be notified to other parties or in response to a request made under the Freedom of Information Act 2000. Applicants are referred to paragraph 21 of Schedule 2 of the Regulations which sets out NHS England's responsibilities in relation to information provided in this application form which an applicant advises is confidential. Information regarding the applicant 1.1 Full name and correspondence address of the applicant (i.e. the contractor who will continue to provide services) 1.2 Applicant’s legal entity I/we am/are applying as a: (Please tick relevant box. Only one box may be selected. GPhC registration numbers only need to be provided for pharmacy applications.) Sole trader My GPhC registration number is ………………………… Partnership Please list each partner and their GPhC registration number:
Chapter 12A Annex 1 Application Form Application in respect of a consolidation onto an existing site Application in respect of a consolidation onto an existing site in the area of: .…………………………………………… (insert name of health and well-being board). A consolidation application must be in relation to pharmacy premises that are located within the area of a single health and wellbeing board. This is an application in respect of a consolidation onto an existing site and as such is an excepted application under regulation 26A(1) of the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 (the "Regulations"). Please complete this form as legibly as possible. Applicants should note that information provided in this form may be disclosed where this application is required to be notified to other parties or in response to a request made under the Freedom of Information Act 2000. Applicants are referred to paragraph 21 of Schedule 2 of the Regulations which sets out NHS England's responsibilities in relation to information provided in this application form which an applicant advises is confidential. Information regarding the applicant 1.1 Full name and correspondence address of the applicant (i.e. the contractor who will continue to provide services) 1.2 Applicant’s legal entity I/we am/are applying as a: (Please tick relevant box. Only one box may be selected. GPhC registration numbers only need to be provided for pharmacy applications.) Sole trader My GPhC registration number is ………………………… Partnership Please list each partner and their GPhC registration number:
annex-1-application-respect-consolidation-onto-existing-site.docx