Application for the registration of persons

Local Government (Miscellaneous Provisions) Act 1982 as amended by Section 120 of the Local Government Act 2003

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Your application

To carry on the practice of acupuncture, business of tattooing, business of cosmetic piercing, business of electrolysis, business of semi-permanent skin colouring.

Application(Required)

New application

Variation

Current licence number(Required)

Describe briefly the nature of the variation(Required)

I/We hereby make application under the provisions of the above Acts for registration to carry on the practice/business of(Required)

(please tick boxes as applicable)

Acupuncture- under Section 14

Tattooing- under Section 15

Semi-permanent skin colouring- under Section 15

Cosmetic body and ear piercing- under Section 15

Ear piercing only- under Section 15

Electrolysis- under Section 15

Other

Document upload

Please upload copies of relevant qualifications(Required)

Drop files here or

Max. file size: 50 MB.

Please upload a copy of your public liability insurance(Required)

Max. file size: 50 MB.

Please upload a copy of your consent(Required)

Max. file size: 50 MB.

Please upload a copy of your after-care forms(Required)

Max. file size: 50 MB.

Premises details

Name of premises(Required)

Postcode

Search Postcode

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address

Address(Required)

House name/House No./Flat no Address line 1 Address line 2 City Postcode

Email address(Required)

Enter Email Confirm Email

Contact telephone number(Required)

Application details

Have any of the persons specified in the application been registered in this respect with any other Local Authorities?(Required)

Yes

No

Please tell us which authorities(Required)

Has any person specified in this application been convicted of any offence under the Acts?(Required)

Yes

No

What training has been received for dealing with potentially harmful chemicals, needles, body fluids and hazardous waste?(Required)

Please provide particulars of relevant qualifications and details of certificate(s)

Note - Original certificates may be required for inspection when routine Health and Safety Inspections are carried out.

Are you a member of a professional body or association?(Required)

Yes

No

Please tell us which professional body or association you are a member of

Declaration

Declaration(Required)

I certify that the particulars included in this application are correct for the registration applied for.

Applicant details

Name(Required)

Prefix First Last

Date of birth(Required)

Postcode

Search Postcode

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address

Address(Required)

House name/House No./Flat no Address line 1 Address line 2 City Postcode

Email address(Required)

Enter Email Confirm Email

Contact telephone number

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SCP Reference

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SCP Request ID

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SCP Request Status

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SCP Request Message

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SCP Payment Info

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Staff ID

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Date