Statutory information

Name of Licence Holder:*

Please note this needs to be a legal entity (e.g. NOT a centre). See Help Notes for guidance.

Main purpose of the operations to be covered by this licence:* Address line 1: * Address line 2: Address line 3: Town/City: * County: Postcode: * Tel:* Fax:

Name:* Tel:* Fax: Mobile: Email: *

Name:* Address line 1: * Address line 2: Address line 3: Town/City: * County:* Postcode: * Tel:* Fax: Website:

Please indicate when activities covered by this application are not available for inspection, giving reasons:*

Your name:* Your position:*

Please remember we cannot complete the application process without the licence fee being submitted with your application. If you choose to print off the form and return it by post, please enclose payment of your £715 renewal fee. Alternatively, please proceed to the online payment.

Please note: There is a £9.00 surcharge for Credit Card payment.

This amount will be automatically added to the fee if the payment is made by credit card.

We accept the following debit and credit cards: