Application for Therapist

Registration or Exemption

Massage and Special Treatment 2018-19

/
Complete, sign and sentthis form to:
Hammersmith & Fulham Council
Commercial Services Team
PO Box 66532
London W8 9GJ
020 8753 1081

Please read guidance notes at
1 / Title (Mr. Ms. Mrs etc)
First name(s)
Surname
Maiden name (if appropriate)
Home address
Postcode
Daytime telephone number
E-mail address
2 / Date of birth
National Insurance Number
3 / Is this a renewal registration application? / YES / NO
4 / Where will you be working in
Hammersmith & Fulham? /

Salon / Leisure Centre / Hotel / Other:

Business name
Business address
Postcode
5 / Are you registered as a therapist with any other Local Authority /

YES / NO

Name of Local Authority
Registration number
Copy of badge/certificate enclosed /

YES / NO

Please tick the licensable treatments you intend to offer

Acupuncture / Micro Blading
Aromatherapy / Micro current Therapy /
Non-surgical face lifts
Body Massage / Micropigmentation/
semi-permanent make-up
Body Piercing / Nail Extensions
Cosmetic Lasers / Nose Piercing
Derma Roller/ Pen / Oxygen Therapy
Ear and Nose Piercing / Pedicure
Electrolysis / Radio Frequency
Facial Steamer / Reflexology
Indian Head Massage / Sauna
Infra –red treatment / Spa/ Jacuzzi
Intense Pulse Light (IPL) / Steam Room/ Bath
Laser Lipolysis / Tattooing
Laser Tattoo Removal / Ultra-violet tanning / sunbed
LED (Light Emitting Diode) / Ultra Sonic
Manicure

Please tick other treatments you offer which do not require licence or therapist registration

Body wraps / Threading / Waxing
Bleaching skin / Spray tan / Hairdressing
Micro Dermabrasion / Make Up application / Henna tattoo
Eyelash treatments / Eyebrow shaping / Skin peels
Basic facial / Eyebrow tinting / Injectables
Other…… / Other… / Other…
I am applying for Therapist Registration
and confirm £85 has been paid
Registration is valid for 3 years / Cheque enclosed Yes / No
Paid by phone Yes / No
Payment date…………..
I am applying for Therapist Exemption
and confirm £79 has been paid
Exemption is valid for length of membership of an approved exempt body / Cheque enclosed Yes / No
Paid by phone Yes / No
Payment date…………..
I enclose training certificates for all treatments to be offered / Yes / Not applicable
I enclose official translation of certificates in any language other than English and an assessment letter from NARIC / Yes / Not applicable
I enclose evidence of membership of an approved exempt body / Yes / Not applicable
I understand and consent to the disclosure to the Council by the Police of the record of any criminal convictions(s) that I have, other than spent convictions within the meaning of the Rehabilitation of Offenders Act 1974. / Yes / No
Signed ………………………………………..
Name…………………………………………… / Date……………………………..
You must not carry out and massage or special treatments until your registration or exemption has been approved. / If your application is incomplete it will not be accepted.

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