Submit PHPLS application

Please use this form to submit your application and make payment. We will be in touch, shortly.

PHPLS Application

Application Form for PHPLS

Personal Details

Name(Required)
Badge Name(Required)
Address(Required)

Create a username and password

Password(Required)
Strength indicator
[Type No, if you have no special needs]
[i.e. Gluten free, Any allergy, Halal, No Beef, No Pork etc. Type No, if you have no special dietary needs]

Professional Details

[Please choose Not Applicable for any section that is not appropriate for you]
(UK applicants only) – [Type N/A if you don’t have any of these number]
Which NHS Health Board or NHS Trust do you work in?(Required)
Address of Hospital or Institution(Required)
Max. file size: 10 MB.

Accommodation Requirements

MM slash DD slash YYYY
MM slash DD slash YYYY

Consent

This field is for validation purposes and should be left unchanged.