OFFICIAL SENSITIVE
Version Date:
To be completed by applicant
ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Application for an Establishment Licence (Issued under Section 2C)
To be completed by the applicant for Licence
Please use BLOCK CAPITALS, PRINTING OR TYPESCRIPT
1
APPLICANT FOR LICENCE (INDIVIDUAL)
a.
b.
c.
d.
e.
f.
TITLE (e.g. Mr, Dr)
DATE OF BIRTH
SURNAME
FORENAMES
QUALIFICATIONS OR HONOURS (e.g. BSc, MBE)
POSITION HELD
ADDRESS FOR CORRESPONDENCE
POST CODE
g. TEL NUMBER
EMAIL
h.
How does your position or experience enable you to keep to the licence conditions?
2
ESTABLISHMENT TO BE LICENSED IN GREAT BRITAIN
a.
NAME OF ESTABLISHMENT:
b.
ADDRESS
3
Is the establishment to be:
4
a.
a Scientific Procedure Establishment
b.
a Breeding Establishment
c.
a Supplying Establishment
YES
NO
Declaration by the Applicant:
I understand the terms and conditions under which I may hold a licence under the Animals (Scientific Procedures)
Act 1986 for the establishment described in the attached schedule. I have received, read and hold a copy of the
Home Office Guidance on the operation of the legislation.
SIGNATURE
DATE:
09/07/2014
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
Version Date:
To be completed by applicant
OFFICIAL SENSITIVE
ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Application for an Establishment Licence
To be completed by the applicant for Licence
Please use BLOCK CAPITALS, PRINTING OR TYPESCRIPT
5
APPLICANT FOR LICENCE (CORPORATE)
a.
b.
NAME OF COMPANY/BUSINESS
ADDRESS
POST CODE
g. TEL NUMBER
6
ESTABLISHMENT TO BE LICENSED IN GREAT BRITAIN
a.
NAME OF ESTABLISHMENT:
b.
ADDRESS
7
Is the establishment to be:
8
a.
a Scientific Procedure Establishment
b.
a Breeding Establishment
c.
a Supplying Establishment
EMAIL
YES
NO
I endorse this application for an establishment licence
I understand the terms and conditions under which this establishment may hold a licence under the Animals
(Scientific Procedures) Act 1986 as described in the attached schedule. I have received, read and hold a copy of the
Home Office Guidance on the operation of the legislation.
POSITION HELD IN ESTABLISHMENT
this should be the Named Compliance Officer (see Notes):
SURNAME
FORENAME
SIGNATURE
DATE:
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
09/07/2014
Version Date:
To be completed by applicant
OFFICIAL SENSITIVE
ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Establishment Licence (Please complete a separate sheet for each person)
NAMED VETERINARY SURGEON (NVS)
a. TITLE (e.g. Mr, Dr)
b. SURNAME
c. FORENAMES
d. PROFESSIONAL ADDRESS
e. TELEPHONE No AND EXTENSION
E-mail address
f. Qualifications
If NVS training completed please give course and year:
.
g. Facilities (units or rooms) of establishment licence or type of work for which
responsible:
.
.
.
.
.
.
.
.
h. Signature:
Date:
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
09/07/2014
Version Date:
To be completed by applicant
OFFICIAL SENSITIVE
ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Establishment Licence (Please complete a separate sheet for each person)
NAMED PERSON RESPONSIBLE FOR DAY TO DAY CARE OF ANIMALS (NACWO)
a. TITLE (e.g. Mr, Dr)
b. SURNAME
c. FORENAMES
d. PROFESSIONAL ADDRESS
e. TELEPHONE No AND EXTENSION
E-mail address
f. Qualifications
If Named Care Person (NACWO) training completed please give course and year:
.
g. Facilities (units or rooms) of establishment licence (or species) for which responsible:
.
.
.
.
.
.
h. Signature:
Date:
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
09/07/2014
Version Date:
To be completed by applicant
OFFICIAL SENSITIVE
ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Establishment Licence (Please complete a separate sheet for each person)
NAMED INFORMATION OFFICER (responsible for provision of information relevant to the
species to licence holders)
a. TITLE (e.g. Mr, Dr)
b. SURNAME
c. FORENAMES
d. PROFESSIONAL ADDRESS
e. TELEPHONE No AND EXTENSION
E-mail address
f. Qualifications
.
.
g. Signature:
Date:
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
09/07/2014
Version Date:
To be completed by applicant
OFFICIAL SENSITIVE
ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Establishment Licence
NAMED PERSON RESPONSIBLE FOR ENSURING COMPLIANCE
a. TITLE (e.g. Mr, Dr)
b. SURNAME
c. FORENAMES
d. PROFESSIONAL ADDRESS
e. TELEPHONE No AND EXTENSION
E-mail address
f. Qualifications
.
.
g. Signature:
Date:
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
09/07/2014
Version Date:
To be completed by applicant
OFFICIAL SENSITIVE
ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Establishment Licence (Please complete a separate sheet for each person)
NAMED TRAINING AND COMPETENCY OFFICER
a. TITLE (e.g. Mr, Dr)
b. SURNAME
c. FORENAMES
d. PROFESSIONAL ADDRESS
e. TELEPHONE No AND EXTENSION
E-mail address
f. Qualifications
.
.
g. Signature:
Date:
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
09/07/2014
Version Date:
To be completed by applicant
OFFICIAL SENSITIVE
ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Licensed Establishment Schedule of Premises
To insert additional rows click in the last cell & press the tab key
Location or Building
Area
[provide unique identifier (see note)]
(The area must comply with the
provisions of Code of Practice relevant
for the holding and use of the animals
being held there.)
Suitability Codes
Holding Codes
[Animals for which
area can be made
suitable - see list]
[see list and
note]
Any notes
about the
area
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
09/07/2014
Version Date:
To be completed by applicant
OFFICIAL SENSITIVE
Requests for Other Authorisation
Do you seek authorisation for the following;
Methods of killing not specified in Schedule 1
YES
NO
If yes please complete sections below
Specify method
Specify type/description of animal to which it is to be
applied
Note: Such methods can be authorised only if the Secretary of State is satisfied on the basis of scientific evidence that the
method is at least as humane as one of the methods of killing appropriate to that description of animal under Schedule 1, see
(Section 15A(6)). Please provide evidence for your assertion that the method(s) specified above is/are at least as
humane as a Schedule 1 method appropriate to that type of animal..
Setting free and re-homing of protected animals after completion of a series of regulated
procedures
YES
NO
If yes please complete sections below
Provide details of the circumstances under which this
may occur, see (Section 17A of the Act, subsection 3
and 4).
Provide details of the animals to be set free or re-homed
09/07/2014
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
Version Date:
To be completed by applicant
OFFICIAL SENSITIVE
NOTES SECTION
Establishment Licence:
Establishment licences may be held by an individual or corporate entity.
Where the holder is a corporate entity the responsibilities of the establishment licence holder will be carried
out by the Named Person Responsible for Ensuring Compliance.
If applying as an individual on behalf on an establishment please start at sections 1-4. If applying as a
corporate entity please start at sections 5-8.
Conflict of Interest Declaration for Named Persons:
It is important that any named person responsible for animal welfare under the Animals (Scientific
Procedures) Act 1986 must not be in a position where he or she does not put his/her over-riding welfare
obligations to the animals first. For further details please open link below:
http://www.homeoffice.gov.uk/publications/science-research-statistics/animals/conflict-of-interest
Area
This should be a building, floor, set of rooms or specific room, as appropriate, and should be defined by a
description, code or number. Alternatively reference can be made to areas defined clearly on a plan appended
to this schedule.
Suitability coding list:
Areas should be classified according to their potential to hold particular species. A narrower definition than
that specified below may be chosen e.g. SA (rodent only) if this is appropriate.
Where the area could be made suitable for several groups of species use of combinations of codes is
acceptable.
Small animals (all species not included in the groups specified below) SA
Large animals (agricultural species excluding poultry) LA
Aquatic species (including amphibia) AQ
Birds AV
Dog (DOG),
Cat (CAT),
Equidae (EQU),
Non-human primates
Explanation of holding codes:
STH – Short term holding (i.e. less than 48hr)
NOH – Not for overnight holding
SEP - sterile experimental procedures
Note – all areas are considered to be for long term holding unless specified otherwise and non-sterile
experimental procedures.
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
09/07/2014
Version Date:
To be completed by applicant
OFFICIAL SENSITIVE
The Home Office, in line with the rest of HMG, has implemented the Government Security Classification (GSC). Details of the GSC can be
found at https://www.gov.uk/government/publications/government-security-classifications. Please note that documents and emails you receive
may contain specific handling instructions.
Handling Instructions: Contains personal sensitive information, subject to confidentiality requirements under the Data Protection Act. This
should only be circulated in accordance with ASPA Guidance and stored in a locked secure location.
All government information may be subject to an FOI request and subsequent assessment.
OFFICIAL SENSITIVE
09/07/2014