Application Form

View Eligibility Criteria & Guidelines

Applicant Information

Section A

Name of Pharmacy/Hospital Authority:
Name of Pharmacy Owner/Approved Hospital Authority Contact:

Address of Pharmacy/Hospital Authority
Address
Town/Suburb:	State:	Postcode:

Mailing Address of Pharmacy/Hospital Authority		As Above
Address
Town/Suburb:	State:		Postcode:

Phone Number:		Fax Number:
Email Address:
ABN Number:		Pharmacy s90 PBS Approval No: (for Community Pharmacies only)

Section B

I am an Approved Pharmacist (as per the definition in the Eligibility Criteria & Guidelines)	Go To Section D
I am an Approved Hospital Authority (as per the definition in the Eligibility Criteria & Guidelines)	Go To Section C

Section C – please tick one of the following categories

I am a hospital authority or a multi-purpose centre that operates a pharmacy, and has a full-time pharmacist engaged who has the capacity to provide adequate supervision to a pharmacy pre-registrant that is:

1. located in a defined rural area where there is no community pharmacy within a 30km radius	Go To Section D
2. located in a defined rural area where there is a community pharmacy and I have attached confirmation in writing from the local community pharmacy that they are not willing or able to take a pre-registrant	Go To Section D

3. located in a defined rural area where there is a community pharmacy and I am submitting a joint application with a community pharmacy agreeing to ‘share’ a 12 month placement between the two sites (Please note that the Approved Pharmacist and the Approved Hospital Authority must each fill in individual application forms and submit them together)	Go To Section D

Section D – Pre-registration placement period

6 Months	Start Date:	Finish Date:
12 Months	Start Date:	Finish Date:
Between 6 & 12 Months	Start Date:	Finish Date:

Please provide brief details of how the Rural Pharmacist Pre-registration Incentive Allowance has assisted you to employ a Pharmacy Pre-registrant:

Bank account details to which payments are to be made

Bank:			BSB:		Account Number:
Account Name:

Section E – Pharmacy Pre-registrant

Name:
Address:
Mailing address: As Above
Contact phone number:	Mobile phone contact:
Email address:	Date of birth:
Are you an Australian citizen or permanent resident?	YesNo	Gender:	MaleFemale

(You must be an Australian citizen or permanent resident to be eligible. Please attach evidence).

Name of the institution at which you completed your pharmacy studies:
Name of the relevant State or Territory Pharmacy Board that you are registered with:

Section F

Declaration – Eligible Approved Pharmacist/Approved Hospital Authority (The declaration is a legally binding document and indicates that you have to the best of your knowledge provided true and correct information)

I understand that the following are conditions of the Rural Pharmacist Pre-registration Allowance and that I may lose my entitlement to this Allowance and future Allowances if I do not at all times comply with every such condition.
I declare that:

I am the pharmacist approved under Section 90 of the National Health Act (1953). I confirm that the pharmacy described above is currently actively trading and is expected to continue actively trading for the duration of the placement period [not applicable if an Approved Hospital Authority]. I confirm that I have employed:

for a period of months in accordance with the State or Territory Pharmacy Board requirements applicable in my State or Territory.
I have read and understood the Guidelines and by signing this declaration I am indicating my agreement to abide by the terms of the Rural Pharmacist Pre-registration Incentive Allowance.
The information provided in this application form is true, correct and complete to the best of my knowledge.
If any of the following circumstances occur I will inform the Guild within 21 days and repay any monies that I am not entitled to under the terms of the Rural Pharmacist Pre-registration Incentive Allowance Rules.
- a change in the length of the pharmacy pre-registrant’s employment contract
- sale of the pharmacy described above
- the pharmacy described above ceases to actively trade
- the conditions of the placement no longer meet the requirements of the applicable State or Territory Pharmacy Board
After six months I will provide either a mid-placement report (where the term of employment is greater than 6 months) or a final report (where the term of employment is 6 months) before the next payment can be received. If the term of employment is 12 months, I agree to provide a final report before the last payment is received.

I understand that:

Allowances are limited on the basis of available funds. Lodging an application form does not guarantee that I will receive an allowance.
There may be penalties for providing false or misleading information
Incomplete applications will not be accepted

I agree that:

To participate in processes to enable the short and long term evaluation of the Rural Pharmacist Pre-registration Incentive Allowance

Eligible Approved Pharmacist/Approved Hospital Authority
I accept the above terms and conditions
Name:		Date:

Declaration – Pharmacy Pre-registrant (The declaration is a legally binding document and indicates that you have to the best of your knowledge provided true and correct information)

I declare that I am a Pharmacy Pre-registrant, eligible in accordance with the Eligibility Criteria and Guidelines for the Rural Pharmacist Pre-registration Incentive Allowance to take part in this initiative. I confirm that I have entered into an arrangement to undertake my placement at: for the following period:
Start Date:
Finish Date:

I agree:

To the reporting requirements outlined in the Eligibility Criteria and Guidelines for the Rural Pharmacist Pre-registration Incentive Allowance.
To participate in processes to enable the short and long term evaluation of the Rural Pharmacist Pre-registration Incentive Allowance.
If I supply a non-Australian passport as evidence of permanent residency I allow the Guild to verify my status with the Department of Immigration and Citizenship (DIAC).

I certify that the information provided by us in this application form is true, correct and complete.
Pharmacy Pre-registrant
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 Rural Pharmacist Pre-registration Incentive 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: