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									                                                            LONDON BOROUGH OF CROYDON
                                                        LONDON LOCAL AUTHORITIES ACT 1991/2000
                                                        ESTABLISHMENT FOR SPECIAL TREATMENT

                                                                    APPLICATION FOR A NEW LICENCE

     Please complete all parts of the form and send completed form and copies to the
     appropriate Authorities as detailed below, please do not send any payment with the forms.


Original to:             Environment, Culture & Public Protection Department
                         London Borough of Croydon
                         Taberner House
                         Park Lane
                         Croydon CR9 3BT (Original)         Tel: 020 8760 5436

Copy to:                 Licensing Sergeant                                                     Copy to:                    Chief Officer
                         Metropolitan Police                                                                                LFEPA – South Command Fire Safety
                         71 Park Lane                                                                                       Croydon Fire Station
                         Croydon                                                                                            90 Old Town
                         CRO 1JD                                                                                            Croydon CRO 1AR

I/We hereby apply to the Council of the London Borough of Croydon in pursuance of the provisions of the
London Local Authorities Act 1991/2000, for the licensing of the following premises as an establishment for
special treatment.

Trading Name:                    ..........................................................................................................................................................................

Trading Address: ....................................................................................................
                   ........................................................................................................................................................................

Tel. No of Trading Premises:                                                                                                   Mobile: ........................................................
                                                               ..................................................................................................................................................................



       APPLICANT NAME                                                                                   Private Address                                                                Date of
(Individual or Company name,                                                                                                                                                            Birth
 for companies give details of
         all Directors)
  Full name in Block Capitals




If a Company, Registered or Principal Office:                                                 .........................................................................................................


Address for correspondence if different to above:                                                      ................................................................................................
Please list all treatments for
which a licence is required




Is the applicant the owner/leaseholder of the premises to be licensed.                                                                YES                           NO

If No Name and address of owner of trading premises.

Will the applicant be the responsible person present at the premises on                                                               YES                           NO
a day to day basis.

If not, who will be responsible for the conduct and management of the
premises.

Please list all persons who will be carrying out treatments:


Full name                                                                                       Qualifications/Experience/Date achieved




Tick type of premises to be licensed.

Commercial                      YES                                    NO                       Residential                      YES                                NO




If you require any assistance, have any special needs or would like this information provided in
larger type, in Braille or tape recorded, please contact the Customer Services Officer on 020-
8760-5466. You can also contact us by Minicom on 020 8760 5797, or using Typetalk on 0800
515152.

I/We hereby declare that the particulars given below are true to the best of my/our knowledge and
belief.


Signed:     ...............................................................................................   Date:   ........................................................

            ...............................................................................................           ........................................................

								
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