BPA Application Form

Please select role
Please select Title
Please enter your first name
Please enter your Surname
Please Enter Address First Line
Please Enter Address Second Line
Please enter town/city
Please enter county
Please enter postcode
Please select Country

Please enter Home Phone Number
Please enter Mobile Number
Please enter email

Please enter GPhC reg
Please enter RPS reg no
Please enter Boots staff

Please complete the section below to allow payroll to deduct your subscription directly from your salary.


Please debit from my monthly salary the sum of £8.00 (Eight Pounds) from today for the credit of the Boots Pharmacists’ Association and make similar payments MONTHLY from my salary THEREAFTER until I cancel this order in writing to the CEO, BPA (3 months notice will be required).

Please enter Your First Name
Please enter Your Surname
Please enter Boots Staff no
Please enter Date
If you have been referred to BPA by an existing member, please enter their details in the three boxes immediately below:
Please enter Staff No
Please enter your first name
Please enter your Surname

Thank you for submitting your application. BPA Admin will contact you within the next two working days.