Off-Boarding Employees or Locums

Please complete the following form to remove Fred NXT access for staff no longer employed at your store. You will receive a confirmation email once access has been removed by Fred.

1. Pharmacy group name

2. Pharmacy Name

3. Store phone number

4. Final day of employment for the employee/ locum This question requires a valid date format of DD/MM/YYYY.

calendar

5. Employee/ locum details

	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum
	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum	1	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum
2	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum
3	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum
4	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum
5	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum
6	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum
7	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum
8	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum
9	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum
10	First Name	Last Name	Pharmacist Registration Number	Fred NXT Permissions	Fred NXT Office Roles	This User is a Locum

6. I have completed and checked all sections and I am authorised to request the above changes *This question is required.

Clear

Signature of

7. Position of authoriser *This question is required.

Please enter an 'other' value for this selection.

8. If urgent please add in extra comment