This form is to register an expression of interest to participate in the Victorian Community Pharmacist Statewide Pilot (the pilot).
One application is to be completed per pharmacy. It usually takes between 4 and 6 minutes to complete the form.
Applicants should ensure they have read and understand the following pilot documentation before completing this form:
The applicant must be a natural person who:
- is the owner/director of the organisation (pharmacy); and
- is authorised to make the required declaration and sign the required agreement on behalf of the organisation.
Completion of the EOI cannot be delegated as the owner must make a declaration as part of the EOI process.
Please complete all sections of this form accurately.
Following completion of this expression of interest, your submission will be subject to a validation process.
If you are approved to participate in the pilot you will receive a funding agreement with the Department of Health. Following receipt of the funding agreement, you may indicate your intention to be bound by the agreement by providing any activity outlined in the Pilot.
I have read the relevant documentation and would like to submit an expression of interest for my pharmacy to participate in the pilot.
