Declaration by proposed Corporate Licence Holder Any person making an application should be that under paragraph 7(2)(d) and (g) of Schedule 3 of the Human Tissue Act 2004, the Human Tissue Authority may revoke a licence if it: (a) ceases to be satisfied that the person to whom the licence is granted is a suitable person to be the holder of the licence, and (b) is satisfied there has been a material change of circumstances since the licence was granted. I understand the terms and conditions under which a licence is granted and varied under the Human Tissue Act 2004 and confirm: a) The information provided is true and accurate Yes No b) The Designated Individual has consented to this application Yes No c) I have been authorised to make this application on behalf of the applicant corporate body Yes No Name of person who completed this form: Date: DD/MM/YYYY Please return this application form by email to
Declaration by proposed Corporate Licence Holder Any person making an application should be that under paragraph 7(2)(d) and (g) of Schedule 3 of the Human Tissue Act 2004, the Human Tissue Authority may revoke a licence if it: (a) ceases to be satisfied that the person to whom the licence is granted is a suitable person to be the holder of the licence, and (b) is satisfied there has been a material change of circumstances since the licence was granted. I understand the terms and conditions under which a licence is granted and varied under the Human Tissue Act 2004 and confirm: a) The information provided is true and accurate Yes No b) The Designated Individual has consented to this application Yes No c) I have been authorised to make this application on behalf of the applicant corporate body Yes No Name of person who completed this form: Date: DD/MM/YYYY Please return this application form by email to