Awaiting assessment? Yes No Conditional approval date: DD/MM/YYYY Any further information, such as explanation of the activities covered by the accreditations: To be completed by the Designated Individual Does the establishment have any satellite sites? Yes No If yes, please complete the below information for each satellite site. If you have more than two satellite sites you can copy and paste this part of the form onto a separate sheet. Satellite 1 Name: Address: Postcode: Activities to be licensed under The storage of relevant material which has come from a human the Human Tissue Act 2004 body, for use for Scheduled Purposes other than transplantation under the Human Tissue Act 2004 Activities to be licensed under Procurement the Human Tissue (Quality and Safety for Human Testing Application) Regulations 2007 Processing Storage Distribution Import Export Person(s) Designated Job title Email address Telephone number at the site Primary: Additional: Additional:
Awaiting assessment? Yes No Conditional approval date: DD/MM/YYYY Any further information, such as explanation of the activities covered by the accreditations: To be completed by the Designated Individual Does the establishment have any satellite sites? Yes No If yes, please complete the below information for each satellite site. If you have more than two satellite sites you can copy and paste this part of the form onto a separate sheet. Satellite 1 Name: Address: Postcode: Activities to be licensed under the Human Tissue Act 2004 The storage of relevant material which has come from a human body, for use for Scheduled Purposes other than transplantation under the Human Tissue Act 2004 Activities to be licensed under the Human Tissue (Quality and Safety for Human Application) Regulations 2007 Procurement Testing Processing Storage Distribution Import Export Person(s) Designated at the site Job title Email address Telephone number Primary: Additional: Additional:
Human_Application_Licence_Application_Form_Updated_June_2014.docx