LOCAL GOVERNMENT (MISCELLANEOUS PROVISIONS) ACT 1982 
APPLICATION FOR REGISTRATION TO CARRY ON THE
*PRACTICE OF ACUPUNCTURE AND/OR THE BUSINESS
OF *TATTOOING/*EAR/BODY PIERCING/*ELECTROLYSIS

To: Mid Devon District Council, Licensing Services, Phoenix House, Phoenix Lane, Tiverton.   EX16 6PP

 I/WE HEREBY MAKE APPLICATION under the provisions of the above Act for Registration to carry on (the practice of acupuncture) the business of (tattooing) (ear/body piercing) electrolysis) at the premises detailed below:- 

PARTICULARS

1.    Name(s) of Applicant(s) (IN FULL) 1.
2.    Address(s) of Applicant(s) (i.e. usual place(s) of residence.  In the case of a company or firm, give the address of the registered or principal office below: Address
Company Address

Post Code
2.
Address
3.
Address
3. Name/Address of premises required to be registered. Name:
Address:
 
Tel No.
4.    Description of premises, including number of rooms and particulars of arrangements for cleansing of premises, fittings/equipment and sterilisation of instruments (attach a separate schedule if necessary)
5.    Have you previously been registered in this respect in any other district?  If YES, which? YES        NO
6.    Have you ever been convicted of any offence under the Act?  If so, give details: YES       NO

 A Fee of £100.00   will be paid online when submitting form     or  Cheque by post 

    Signed: .      Date:  

On behalf of: .

 

Human Check: