Isle of Wight Council

	Application for registration to carry on the practice of
	What service are you applying to practise? (Please select one)    Body Piercing  Ear Piercing  Electrolysis Piercing  Tatooing  General Skin Piercing
	Before completing this form please click on the links below to read the Guidance Notes and Byelaws relating to your application. Body Piercing Guidance Notes Ear Piercing Guidance Notes Electrolysis Piercing Guidance Notes Tattooing Guidance Notes General Skin Piercing Guidance Notes MBC Byelaws With respect to Ear Piercing, Electrolysis, Acupuncture, Tattooing  Please tick this box to confirm you have read and accept the MBC Byelaws

	I/we hereby make application under the provisions of the above Act for registration to carry on the practice of at the premises detailed below.
	A fee of £180.00  for registration of premises and £95.00 for registration of each person accompanies this application.   Please state number of people you are applying for ........... x �16 = ............
	This application fee is not refundable in the event of the application being refused or otherwise.

Applicant Details

*

Name of applicant / Company name

Address details (if company or firm, the registered or principal office)

*	Building/house name/number
*	Street
*	Town
	County
*	Postcode
	Name(s) and address(es) of further applicants

	Premises details
	Address of premises required to be registered:

*	Building/house name/number
*	Street
*	Town
	County
*	Postcode
*	Telephone number for contact for inspection of premises

	Is this registration for a new premises?	Yes No
	If yes, please describe the premises including a plan of the treatment rooms and the location of equipment
	If yes, please provide particulars of arrangements for cleansing of premises, fittings and equipment and sterilisation of instruments. A plan may also be requested.

Details of person(s) carrying out the treatment

*	Name 1
	Name 2
	Name 3
	If you need more space please continue here:
	Have any of the above named previously been registered for the above by any other Council? If so, please give details.	Yes No
	Have any of the above named ever been convicted of any offence under the Act? If so, give details	Yes No

	Declaration
	I declare that I have checked the information given on this application form and to the best of my knowledge and belief it is correct. I understand that a false or misleading statement, or that withholding relevant information, may result in the refusal or revocation of the licence and\or may render me liable to prosecution. Signed............................................................... Name................................................................ Date..................................................................

	Data Protection Act 1998
	This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request. The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest. Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law. Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

	Product	Cost	VAT code	GL Code
	Registration of Premises	£180.00	AN	67605732501
	Registration of Person	£95.00	AN	67605732501

Date printed: 07/03/2013