Pre-Payment Certificate Application

PPC Application Form


							Version 2.06

Pharmacy Registration

If you wish to register with the Business Services Authority, to sell Prescription Pre-payment Certificates (PPCs) from your pharmacy on our behalf, please complete the registration form below. Please ensure that you have sufficient authority to make this application from either the owner or head office of the business.

For a copy of the guidance in respect of selling PPCs please click here

Fields marked are mandatory. Please complete all mandatory fields.

Please Note

If you have not read our statement relating to the use of your personal information, please do so now.

Pharmacy Details

Pharmacy OCS Code

Email Address

Title

Mrs

Miss

Other

First Name

Surname

Pharmacy Name

Pharmacy Address 1

Pharmacy Address 2

Pharmacy Address 3

Pharmacy Address 4

Pharmacy Post Code

Telephone Number

Data Protection Act 1998: The Business Services Authority will use the information that you have provided on this application form for the processing of your application. We will not disclose your Personal data to any third party or transfer it outside of the European Economic Area. We may contact you to discuss your application. Your personal data will be deleted from our systems and files no later than 7 years from when the certificate was purchased.