PIMART course registration

Applicant Personal Information

Title

Surname

First Name/s

ID/Passport Number

Country of Issue of ID/Passport

Physical Address

Address Line 1

Address Line 2

City

Region

Zip Code

Country

Postal Address

Address Line 1

Address Line 2

City

Region

Zip Code

Country

Office / Work number

Cellphone number

Gender

Ethnic Group

Highest Degree/ Qualification

Year obtained

Other Degree/ Qualification

Other Degree/ Qualification

Year obtained

Year obtained

Council Number

Employment Details

Name of Pharmacy

Physical address of pharmacy

Address Line 1

Address Line 2

City

State

Zip Code

Country

Trading hours

Category of Employing Institution/ Organisation/ Business

Public

Private

NGO

Other

If other, please specify

Current Job Title

Country where you work

Province where you work

If you are a pharmacy-based nurse, are you NIMART trained?

Yes

If yes, please state NIMART training institution & year completed

Year completed

Training institution

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