Application Form

View Eligibility Criteria & Guidelines

Applicant Information

Name of Pharmacy Owner:
Name of Pharmacy Employing the Pharmacy Assistant:

Address of Pharmacy

Address
Town/Suburb:		State:		Postcode:

Mailing address

As Above

Address
Town/Suburb:		State:		Postcode:

Name of Contact at Employing Pharmacy:
Phone Number:		Fax Number:
Email Address:
ABN Number:		Pharmacy s90 PBS Approval No:

Please provide brief details of how the Aboriginal and Torres Strait Islander Pharmacy Assistant Traineeship Scheme will assist you to employ and support an Aboriginal or Torres Strait Islander Pharmacy Assistant.

Pharmacy Certification
I certify that the information provided by us in this application form is true, correct and complete.
Name:		Date:

Bank Account Details

Bank:		BSB:		Account Number:
Account Name:

Pharmacy Assistant Details

Name of Pharmacy Assistant:

Telephone Number:
Gender:	MaleFemale	Date of birth:

Home Address of Pharmacy Assistant

Address:
Town/Suburb:		State:		Postcode:

Date Employment Commenced:
Title of Nationally Accredited Training Course:
Proof of Aboriginality:
Training Record:
Name of Educational Institution:
Date Of Enrollment:
Date of Commencement of Course:		Anticipated Completion Date:

Pharmacy Assistant Certification
I certify that the information provided by us in this application form is true, correct and complete.
Name:		Date:

Agreement to issue Recipient Created Tax Invoices

Under A New Tax System (Goods and Services Tax) Act 1999

Name of Pharmacy: ABN:

AND

The Pharmacy Guild of Australia – National Secretariat ABN: 84 519 669 143

Hereby agree:

that The Pharmacy Guild of Australia - National Secretariat will issue recipient created tax invoices in relation to the supply of goods or services dealing with the Aboriginal and Torres Strait Islander Pharmacy Assistant Traineeship Scheme to The Pharmacy Guild of Australia - National Secretariat by the Pharmacy/Hospital Authority for a period of time commencing at the date of this agreement until this agreement is terminated with the consent of both parties or is no longer effective as a result of the requirements relating to recipient created tax invoices no longer being met by The Pharmacy Guild of Australia - National Secretariat or the Pharmacy;
that the Pharmacy/Hospital Authority will not issue tax invoices in respect of any supplies covered by this agreement;
that the Pharmacy/Hospital Authority acknowledges that it is registered for GST at the time of entering into this agreement with The Pharmacy Guild of Australia - National Secretariat;
that the Pharmacy/Hospital Authority will notify The Pharmacy Guild of Australia - National Secretariat if the Pharmacy/Hospital Authority ceases to be registered for GST;
that The Pharmacy Guild of Australia - National Secretariat acknowledges that it is registered for GST at the time of entering into this agreement;
that The Pharmacy Guild of Australia - National Secretariat will notify the Pharmacy/Hospital Authority if The Pharmacy Guild of Australia - National Secretariat ceases to be registered for GST;
that The Pharmacy Guild of Australia - National Secretariat will indemnify the Pharmacy/Hospital Authority for any liability for GST and/or penalty payable by the Pharmacy/Hospital Authority that has arisen directly as a result of an understatement of the amount of GST payable, as disclosed on a recipient created tax invoice issued by The Pharmacy Guild of Australia - National Secretariat in respect of a supply covered by this agreement;
that The Pharmacy Guild of Australia - National Secretariat will not indemnify the Pharmacy/Hospital Authority for any liability for GST and/or penalty payable by the Pharmacy/Hospital Authority as a result of the Pharmacy/Hospital Authority failing to comply with any or all of its taxation obligations or actions which are outside of the control of The Pharmacy Guild of Australia - National Secretariat;
that The Pharmacy Guild of Australia - National Secretariat will issue to the Pharmacy/Hospital Authority a copy of the recipient created tax invoices issued under this agreement and retain the original copies for its own records;
that The Pharmacy Guild of Australia - National Secretariat will issue to the Pharmacy/Hospital Authority an adjustment note where a supply made under this agreement is subject to an adjustment event [as defined by Subdivision 19-A of the A New Tax System (Goods and Services Tax) Act 1999];
that all recipient created tax invoices or adjustment notes issued to the Pharmacy/Hospital Authority by The Pharmacy Guild of Australia - National Secretariat under this agreement will contain all necessary information as required under the A New Tax System (Goods and Services Tax) Act 1999 and A New Tax System (Goods and Services Tax) Regulations 1999 (Statutory Rules 1999 No.245); and
that The Pharmacy Guild of Australia - National Secretariat will not issue a recipient created tax invoice earlier than the date of effect of its GST registration, or for any supply received before that date and that The Pharmacy Guild of Australia - National Secretariat will not issue a recipient created tax invoice on or after the date of effect of the cancellation of its GST registration, or for any supply received on or after that date.

Signed by:	John Taylor	Signed by:
Position:	Director Finance	Position:
On behalf of:	The Pharmacy Guild of Australia – National Secretariat	On behalf of:
Date:		Date: