Applicant if a Individual First Name Surname Maiden Name (If Applicable) Residential Address (Proof must be provided) C. Postcode: Telephone Number Email Address Date of Passport/Driving Lic number Convictions List all, if any and unspent convictions in the D. Last five years (Include date(s) and court details) Therapist List the names of all Therapists employed at the premises at the time of E. application Including their Islington registration number: Name Islington Registration Number 1 LN/ 2 LN/ 3 LN/ 4 LN/ 5 LN/ 6 LN/ LN/ 7
Applicant if a Individual C. First Name Surname Maiden Name (If Applicable) Residential Address (Proof must be provided) Postcode: Telephone Number Email Address Date of Passport/Driving Lic number Convictions D. List all, if any and unspent convictions in the Last five years (Include date(s) and court details) Therapist E. List the names of all Therapists employed at the premises at the time of application Including their Islington registration number: Name Islington Registration Number 1 LN/ 2 LN/ 3 LN/ 4 LN/ 5 LN/ 6 LN/ 7 LN/
20170418specialtreatmentsnewpremiseslicence2017.docx