Application for Registration as a
Massage and Special Treatment Therapist 2016-17
This form should be fully completed, signed and
sent to:
Licence number
Hammersmith & Fulham Council
Commercial Services Team
PO Box 66532
London W8 9GJ
Date Received
020 8753 1081
 [email protected]
Fee £67
Please read advice notes at www.lbhf.gov.uk
(Massage and Special Treatment page) before
completing this form
1
This box is for office use only.
CHQ / DC / CC
Exemption requested Yes / No
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
4
5
Is this a renewal registration application? YES / NO
If YES, your previous registration number
and date of expiry
Where will you be working in Salon / Leisure Centre / Hotel / Other:
Hammersmith & Fulham?
Business name
Business address
Postcode
Telephone number
Are you registered as a therapist with any YES / NO
other Local Authority
Name of Local Authority
Registration number
Copy of badge/certificate enclosed YES / NO
BHSD36ta Therapist Registration Application
v6
Page 1 of 2
Indicate the treatments you wish to provide
Level 1 Treatments
Ear Piercing
1-1
Manicure
1-4
Fish Pedicure/Manicure
1-2
Nail Extensions
1-5
Foot detox
Level 2 Treatments
Aromatherapy
1-3
Pedicure
1-6
2-1
Infra –red treatment
2-10
Body Massage - Please specify type
2-2
Micro current Therapy /
Non surgical face lifts
2-11
Chiropody/Podiatry –
not state registered Infra Red
Chiropractic –
not state registered
Facial steamer
Facial with ultra sonic
2-3
2-12
2-4
Oxygen Therapy
Reflexology
2-13
2-5
2-6
Sauna
Spa / Jacuzzi
2-14
2-15
Hydrotherapy
Indian Head Massage
Radio Frequency
Level 3 Treatments
Acupuncture
Body Piercing
2-7
2-8
2-9
Steam Room / Bath
Nose Piercing
2-16
2-17
3-1
3-2
3-6
3-7
Cosmetic lasers
3-3
Lumi Lift/ Lumi facials
Micropigmentation/
semi-permanent make-up
Tattooing
3-8
Electrolysis
3-4
Ultra-violet tanning / sunbed
3-9
Intense Pulse Light (IPL) / Intense
3-5
Laser Lipolysis
3-10
Light Systems (ILS) / LED
Other treatments not listed - please contact us for advice
Treatments not requiring licence or therapist registration – indicate those offered
Dermabrasion (if without light or other treatment)
Bleaching
Ultra-sound fat reduction
Spray Tanning
Threading
Waxing
Eyelash and eyebrow treatments
Make-up application Teeth Whitening Body Wrap
Nail painting only with no shaping
Henna Tattooing
Hairdressing
Skin Peels
Basic facials (unless with massage, steamer or other equipment)
Dermal Fillers, Sclerotherapy, Collagen Implants and Cosmetic Fillers (Must be
administered by a Medical Practitioner only)
I enclose copies of training certificates
Yes / No
I enclose official translation of certificates if they
Yes / No / Not applicable
are in any language other than English and an
assessment letter from NARIC. www.naric.org.uk
I confirm payment of £67 application fee
Cheque enclosed Yes / No
Cheques to be made payable to London Borough
Paid by phone Yes / No
of Hammersmith and Fulham
Telephone 020 8753 1081 to make a payment by
Payment date…………..
Debit Card (no fee) or Credit Card (1.25% fee)
I apply for exemption from application fee
See www.lbhf.gov.uk [Massage and Special
Treatments page] for further information
Evidence of membership of an approved
exempt body enclosed
Yes / No / Not applicable
Signed ………………………………………..
Date……………………………..
Name……………………………………………
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.