I/We hereby make application under the provisions of the above Order for registration to carry on the practice of:
Acupuncture    Electrolysis
at the premises detailed below:
Name(s) of Applicant(s) (in full):
Address(es) of Applicant(s) (i.e. usual place(s) of residence or, in the case of a company or firm the registered or principal office):
Address of premises required to be registered:
Description of premises, including number of rooms,and particulars of arrangements for cleansing of premises, fittings and equipment and sterilisation of instruments: :
Have you previously been registered in this respect in any other district?:	Yes No     If Yes, which:
Have you every been convicted of any offence under the Order?	Yes No     If Yes, give details:
Please note that a registration fee of £25.00 is required for this application. When you click Submit & Pay, you will be re-directed to a secure payment portal.

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Cookstown District Council
Burn Road | Cookstown
Co. Tyrone | Northern Ireland
BT80 8DT
Telephone: 028 8676 2205
Fax: 028 8676 4360
Email: info@cookstown.gov.uk
Website: www.cookstown.gov.uk

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