Statutory Declaration
IN THE MATTER OF SECTION 16(2) (b) OF THE PHARMACY ACT 2007
AND
IN THE MATTER OF RULES 18 & 19 OF THE PHARMACEUTICAL SOCIETY OF IRELAND (REGISTRATION)
RULES 2008 (SI NO. 494 OF 2008)
AND
IN THE MATTER OF AN APPLICATION BY
______________________________________________________________
(here insert the name of the applicant)
To Have Their Qualification Recognised As a Qualification Appropriate For Practice In The State
I __________________________________ of _____________________________________________
(here insert name of applicant) (here insert your usual residential address)
do solemnly and sincerely declare as follows:
1. I am one and the same person as _____________________________________________ the
(here insert your name)
applicant in the Form of Application for recognition of a third country pharmacist qualification
to which this declaration relates.
2. All the information provided by me in the said application form is to the best of my
knowledge, information and belief true, accurate, correct and complete.
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3. The copies of my birth certificate, my current passport (and if applicable my marriage
certificate) which accompany my said application are true copies of the original documents
which are themselves authentic.
4. The four passport sized photographs which I have provided as part of this application
represent a true current likeness of me the declarant.
5. The copies of any third level degrees, diplomas, certificates or other educational testamentary
documents which accompany my application form are true copies of the originals which are
themselves authentic.
6. Insofar as there is any difference between my name as it appears in the said Form of
Application and/or in this declaration and/or in the various documents which accompany
same I say that I am one and the same person as the person mentioned therein and I will if
called upon so to do by Pharmaceutical Society of Ireland (PSI) provide further evidence to
that effect.
7. I undertake and agree with PSI to produce for inspection and comparison the originals of all
documents which accompany my said application when called upon so to do.
8. Insofar as any of the documentation which accompanies my said application is written in a
language other than English, I have procured an English language translation thereof from a
professional translator. The said professional translation into English is in each case attached
to the copy of the said document which it purports to translate. To the best of my knowledge,
information and belief, the English translations of the said several documents are true and
correct.
9. I am aware that under Section 6 of the Statutory Declarations Act 1938 (as amended) it is in
Ireland a criminal offence punishable by fine and/or imprisonment for a person to swear a
Statutory Declaration which contains information that is to their knowledge false or
misleading.
I make this solemn declaration conscientiously believing the same to be true for the benefit of the
Pharmaceutical Society of Ireland by virtue of the Statutory Declarations Act 1938 (as amended).
DECLARED before me
__________________________________________________________________________________
(insert name in capitals)
a Notary Public / Commissioner for Oaths / Peace Commissioner / Practising Solicitor
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(Person authorised by
__________________________________________________________________________________
(here insert authorising statutory provision)
to take and receive Statutory Declarations)
by
___________________________________________________________________________________
(here insert name of the person swearing the declaration in capitals)
who is personally known to me or who was identified to me by _______________________________
(here insert name of
identifying person)
who is personally know to me at
__________________________________________________________________________________
___________________________________________________________________________________
(here insert address at which declaration was sworn)
In the County/City of _____________________
This _____________________________ day of _____________________________ 20_____
___________________________________ _______________________________________
Signature of Applicant Signature of person authorized to take
declaration
Data Protection
The PSI takes its data protection obligations seriously. All personal information submitted by you will be
treated in accordance with Data Protection legislation. Please review the Data Protection Statement
(bit.ly/PSIDataProtection) on our website for details of our use of your information and your rights in relation
to this.
