Application For An Extension Licence To Carry Out An Activity

Form 2

Application For An Extension 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.

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 ? (Please state your last licence’s Serial Number) *

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

7- Why do you wish to apply for an extension of your licence? *

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

9- What period do you wish to have your licence extended for: *

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