Emergency Application For A Temporary Licence To Carry Out An Activity

Form 5
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Emergency Application For A Temporary Licence To Carry Out An Activity Described By Section 192D of the Public Health Act

1- Name *

2- Business Address *

2- Business Address

City

State/Province

Zip/Postal

Country

3- Registered Address (if different)

City

State/Province

Zip/Postal

Country

4- Can you please give details of your telephone number, fax number or email code.

Phone Number *

Fax Number (if any)

Email Address *

5- When did you last apply for a licence to carry out an activity prescribed by section 192D of the Public Health Act ? (Please state your last licence’s Serial Number) *

6- Have any of your replies contained in your last application materially changed in the interim? Please give full details. *

7- Has your organisation been fined , judicially or administratively reprimanded or otherwise suffered any sanction resulting from any failure to uphold its legal duties? *

8- Why do you wish to apply for a temporary licence? *

9- What period do you wish to have your licence granted for? *

10- What is the nature of your emergency? *

11- For what reason(s) is an application on Form 1 not possible? *

12- Do you undertake to make a full application on Form 1 as soon as is reasonably possible? *

Applicant will be required to sign application form prior to document being issued by the Agency.

I certify that the information contained in this Application is true to the best of my knowledge and belief. *

Yes

* obligatory fields