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ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Application for a Personal Licence
Use this form for new applications and/or amendments and/or reviews to licences.
Guidance notes for the completion of this form are on the DHSSPS website.
PART 1 To be completed by the personal licence applicant
Please COMPLETE IN TYPESCRIPT
1
2
a.
TITLE (e.g. MR. etc.)
b.
SURNAME
c.
FORENAMES
If you have previously been known by another name please give that name
a.
SURNAME
b.
FORENAMES
3 a. PRIMARY AVAILABILITY ADDRESS
FROM WHICH YOUR APPLICATION IS
BEING MADE
(Please note: Work under the personal
licence will not be limited to this establishment)
Title:
Address:
b. PROFESSIONAL EMAIL ADDRESS OF
APPLICANT
c. PROFESSIONAL TELEPHONE
NUMBER (AND EXTENSION) OF
APPLICANT
d.
4
5
MOBILE PHONE NO. (optional)
DATE OF BIRTH
(Please complete in day, month, year order e.g. 01/02/1956)
a.
Have you previously held a personal licence ?
YES
NO
TICK APPROPRIATE BOX
b.
If yes, please give (if known) the reference number and the year of expiry or
revocation
PIL
YEAR
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6
PERSONAL LICENCE APPLICATION FORM
Have you completed an accredited course of training to meet DHSSPS requirements?
YES
NO
YES
NO
(Tick appropriate box)
6a Have you enclosed copies of any Certificate(s) for the training modules successfully
completed?
(Tick appropriate box)
6b Which part(s) of modular training are you requesting exemption from?
6c Provide evidence to justify the exemption request from modular training.
7
Other relevant experience and training (see notes)
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8
The procedures and animals for which you seek authority
(Please continue on additional sheets if necessary)
a. Procedure
Category
A
Minor/minimally invasive procedures not
requiring sedation, analgesia or general
anaesthesia
B
Minor/minimally invasive procedures involving
sedation, analgesia or brief general anaesthesia
Plus - surgical procedures conducted under
brief non-recovery general anaesthesia
C
Surgical procedures involving general
anaesthesia.
Plus – administration and maintenance of
balanced or prolonged general anaesthesia
D
Use of neuromuscular blocking agents
If YES, then please provide evidence of
training, qualifications and experience (see also
Home Office Guidance on the use of NMBA)
E
Procedures conducted in accordance with a
project licence for education and training
If YES, then please provide the project licence
number under which authority you will be
working
(i) number………………
F
Other (Please provide details)
(i) details……
PERSONAL LICENCE APPLICATION FORM
b. Animal(s)
c. Tick if Requested
(Tick Appropriate Box)
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PERSONAL LICENCE APPLICATION FORM
9
Declaration by the applicant
a. I understand the terms and conditions under which I may hold a licence under the Animals (Scientific Procedures) Act
1986, and I have read all relevant Home Office Guidance on the operation of the legislation.
b. I understand that I am guilty of an offence if for the purpose of obtaining a licence under this Act I furnish
information which I know to be false or misleading in a material particular or recklessly furnish information which is false
or misleading in a material particular.
c. I understand that if the establishment shown on the licence ceases to be my sole or primary place of work then the
holder of the establishment licence may on my behalf request the DHSSPS to revoke this licence.
10
SIGNATURE:________________________________ DATE: __________________
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ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Application for a PERSONAL Licence
PART 2 To be completed by the NAMED TRAINING AND COMPETENCE OFFICER (for new applications
only)
PART 3 (overleaf) to be completed by the NAMED TRAINING AND COMPETENCE OFFICER (for
amendment requests or reviews)
Please COMPLETE IN TYPESCRIPT
11
12
a.
TITLE
b.
SURNAME
c.
FORENAMES
d.
POSITION OR APPOINTMENT HELD
a.
ADDRESS FOR CORRESPONDENCE
POSTCODE
b.
13
TELEPHONE No AND EXTENSION
Declaration by the Named Training and Competence Officer
I endorse this application for a new personal licence
a. I have knowledge of the education, training, experience and character of the applicant.
b. I understand that I am guilty of an offence if for the purpose of assisting another person to obtain a licence under this
Act I furnish information which I know to be false or misleading in a material particular or recklessly furnish information
which is false or misleading in a material particular.
c. The applicant has a command of English sufficient for him/her to understand the terms and conditions under which
he/she may hold a licence under the Animals (Scientific Procedures) Act 1986, which have been explained to him/her.
14
SIGNATURE: __________________________________ DATE: _______________
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ANIMALS (SCIENTIFIC PROCEDURES) ACT 1986
Application for a PERSONAL Licence
PART 3 To be completed by the NAMED TRAINING AND COMPETENCE OFFICER (for amendment
requests or reviews)
Please COMPLETE IN TYPESCRIPT
15
16
a.
TITLE
b.
SURNAME
c.
FORENAMES
d.
POSITION OR APPOINTMENT HELD
a.
ADDRESS FOR CORRESPONDENCE
POSTCODE
b.
TELEPHONE No AND EXTENSION
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a. I endorse this application for change(s) or continuation to hold a personal licence at the availability at Section 3.
b. I confirm that the applicant has the necessary modular training and/or equivalent current personal licence authority
that permits the conduct of regulated procedures and use of animals described in Section 8 of this form.
c. I understand that I am guilty of an offence if for the purpose of assisting another person to obtain a licence under
this Act I furnish information which I know to be false or misleading in a material particular or recklessly furnish
information which is false or misleading in a material particular.
18
SIGNATURE: __________________________________ DATE: _______________
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