First Name / Given Name:

	Surname / Family Name :
	
Student Number:

	Contact Mail/ Telephone :

Assignment Title:

□ 1 – Community Pharmacy 		□ 2 – Hospital Pharmacy
□ 3 – Industrial Company	
			Name of the Pharmacy/Hospital/Company:

	

1.	I declare that the attached work is all my own, and that where I have quoted from or referred to the opinions or writings of others, these have been fully and clearly acknowledged.
2.	I am aware of the consequences of late submission.
3.	By signing below I agree to the terms and conditions regarding the plagiarism.

Student Signature: ………………………………… Date Submitted: …………………………………	

STAFF USE	

Overall Mark: ………………………
	
FEEDBACK COMMENTS: (Some staff may also provide structured feedback on an additional feedback form)

	

             On Time
             	              Late Submission