Application For A Duplicate Licence To Carry Out An Activity

Form 6 - Application For A Duplicate 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- Telephone 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 ? Can you please supply as much details as possible, including your licence’s Serial Number. *

6- Why do you wish to apply for a duplicate of your licence? *

7- If your licence has been lost or stolen, have you reported the matter to the Police. *

8- When does your licence expire? *

I undertake to surrender the original Licence to the Government should it return to my possession.

Date *

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