Application for the Registration of the Practice of Acupuncture, Ear-Piercing, Electrolysis and/or Tattooing		
LOCAL GOVERNMENT (MISCELLANEOUS PROVISIONS) ACT 1982	
 
I hereby make application under the provisions of the above Act for the registration of a 
Practitioner		Premises		Practitioner and Premises		

carrying on the practice(s) of (indicate as required)

Acupuncture		Tattooing		Ear-Piercing		Electrolysis		

Applicant Details	
Name	
Address	
Date of Birth	
Contact Telephone Number	

Premises at which the practices are to be carried on	
Name or Trading Name of Premises	
Address of premises to be registered and at which the establishment is carried on or proposed to be carried on	
The Nature of the Establishment	
Description of premises, including number of rooms and particulars of arrangements for cleansing of premises; fittings and equipment and sterilisation of instruments. (attach separate schedule if necessary)	

Qualifications and Applicant History	
Give details of technical qualifications, training courses, diplomas, experience etc, of the applicant for the carrying on of that business.  (Evidence of qualifications must be submitted in respect of new applicants).	
Have you previously been registered in this respect in any other district?  If so which?	YES/NO	

Convictions	
Have you ever been convicted of any offence under the Act? If so, give details.	YES/NO	
Please quote details of any convictions or charges outstanding in respect of all offences (or alleged offences).  If you disclose a conviction which is regarded as ‘spent’ under the Rehabilitation of Offenders Act, 1974, it will be ignored.
If you have nothing to declare please write in ‘NONE’. Continue on a separate sheet if required.	
Date	Court	Offence	Sentence	
				
Have you been involved in any incident which may lead to Court proceedings being taken against you? If so, please supply full details.	

Declaration	
I certify that the above answers are true and understand that if there are any omissions or false statements my application may be refused or, if a licence has been issued, it will be liable to immediate suspension or revocation.
(In the case of an association, society, company or other body the signature of the managing director secretary or other responsible officer is required and should be accompanied by the position held)

Applicant Signature
Date	

Please return your completed form with the fee (made payable to Redditch Borough Council) and any relevant supporting documents to either:
Licensing
Redditch Borough Council
Town Hall
Walter Stranz Square
Redditch
Worcestershire
B98 8AH
	Worcestershire Regulatory Services
Wyre Forest House
Finepoint Way
Kidderminster
Worcestershire
DY10 1NW 
Email: wrsenquiries@worcsregservices.gov.uk
Telephone: 01905 822799