PHARMACIST PARTICULARS SHEET1 (to be filled by all registered pharmacists)

  1. Personal Data

Surname:……………………………………………………………

Names:………………………………………………………………………………………………….

Date of Birth (dd/mm/yyyy):……………………………………………………………

Sex: M / F

Place of birth:……………………………………………………………………………………….

Nationality:…………………………………………………………………………………………..

Id card number:…………………………………………………………………………………..

Registration No.: ………………………………………..Registration date: …………………………………..

Telephone No.(Res.): ………………………………… Mobile: ……………………………………………………

Email address:…………………………………………………………………………………………………………………

  1. End-of-secondary school qualifications

Title / Year / Index No. / Institution / Subjects passed at "A" level at one sitting / A Level Grade / A Level points / Aggregate Points
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2
3
  1. Tertiary Education

Date of enrolment in Pharmacy School / University or other institution:………………………

Date when applicant passed final examinations:…………………………………………………………….

Details of qualifications:…………………………………………………………………………………………………..

Title / Graduation Date / Name of Institution / Country / Period attended
  1. Pre-Registration Training

Evidence of following at least one year’s approved registration training

Ref. and date of approval of training by the Council / Institution / Address / Start Date / End date / Tutor'sname / Tutor's qualifications / Name of Institution validating the training / Total duration of training
  1. Pre-registration examination

Date:………………………………………………….

Name of examining body: ……………………………………………………………………………………………

Result:…………………………………………………………………………………………………………………………..

  1. Evidence of Registration in another Country

Title / Date / Registering Body / Country / Registration No. / Validityperiod
  1. Record of experience as pharmacist in a foreign country

Country / Date of registration as a pharmacist / Working Site / Full Address / Capacity / Period of employment
  1. History of postings in Mauritius

Name of Pharmacy / Address / Start Date / End date / Hand-Over to
1
2
3
4
5
6
7
8
9
10
11
12
  1. Registration details in Mauritius

Registering body:………………………………………………………………………………………………………

Date of first registration:………………………………………………………………………………………….

Registration number:……………………………………………………………………………………………….

  1. Record of CPD Status and registration (applicable as from 2018)

Prescribed No. of CPD points / Points attained / Exemption (Y/N) & Ref. / Registered (Y/N) / Receipt Number
2018 / 6
2019 / 9
2020
2021
2022
  1. Record of additional qualifications in the field of pharmacy

Title:…………………………………………………………………………………………..

University / Tertiary Education Institution:……………………………………………………………………….

Country:…………………………………………………………………………………….

Duration of study:…………………………………………………………………….

TEC2 ruling (if applicable): ………………………………………………………………………………………………….

Council ratification date:…………………………………………………………………………………………………….

Registration Receipt Number for additional qualifications:……………………………………………….

L. Record of disciplinary procedures

Council Ref. / Nature of complaint / Summary Proceedings / Council decision & date / Charges preferred / Tribunal Findings / PSC Ref. (if applicable) / Council Decision (R/SR/S/D / Start date of sanction
Ref / Date / G/NG/PG / Date
1
2
3
4
5

1Please refer to guidelines for correct entries

2With the enactment of the Education and Training (Miscellaneous Provisions) Act 2005, which was proclaimed on 01 July, 2005,applications for the recognition and equivalence of qualifications are now dealt with at:

(i)The Tertiary Education Commission (TEC) regarding qualifications at post-secondary and Tertiary level.

(ii)The National Equivalence Committee (NEC) regarding qualifications at primary and secondary level education

  1. Declaration

I, ………………………………...…………...……… declare that -

(a) all the particulars given above are to my best knowledge and belief true and accurate;

(b) I am of good character and have not been convicted of any crime involving fraud or other dishonesty in any country;

(c) I am not under suspension under the laws of any country for or on account of any negligence or infamous conduct or any professional misconduct or malpractice;

(d) I have not been struck off the list of persons entitled to practicepharmacy in any country; and

(e) I am not incapacitated by reason of any mental impairment.

Date: ………………… Signature: ………………...…………

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