Fillable Form 0941130873: (Mansfield District Council)

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Form 0941130873: (Mansfield District Council)

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The Form 0941130873: (Mansfield District Council) form is 3 pages long and contains:

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Country of origin: UK
File type: PDF

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Environmental Health
Application for Licence to Keep Dangerous Wild
Animal(s)
DANGEROUS WILD ANIMALS ACT 1976
You can complete this form in one of the following ways:
1. Print off the form, then complete by hand. Please enter your details clearly and in block capitals, well inside each
box.
2. Complete the form on your computer, then print off. NOTE: Any signatures must be signed by hand.
Please return to Mansfield District Council, Civic Centre, Chesterfield Road South, Mansfield, Notts NG19 7BH.
Title (Mr, Mrs etc)
Name
Postal Address
Postcode
Telephone Number
E-mail Address
Application Details
Address of Premises
where animal(s) is / are
to be kept
Postcode
0941130873
13087
Application Details (continued)
Species of Animal(s) to
be kept (give scientific
name if possible)
Numbers to be kept
Total
Female
Male
Is it intended to breed or attempt to
breed from these animals?
Yes
No
Description and dimensions of accommodation to be used
Description of type of food to be supplied and source
Details of Insurance Policy held to cover liability for damage caused
Company
Policy Number
Expiry Date
/ /
Amount
4110130875
I HEREBY DECLARE that I am over 18 years of age and not disqualified by being convicted of any
offence at any time under the Protection of Animals Acts 1911 to 1964, the Protection of Animals
(Scotland) Act 1912, the Protection of Animals Act 1934, the Pet Animals Act 1951, the Animal
Boarding Establishments Act 1963, the Riding Establishments Acts 1964 and 1970 or the Breeding
of Dogs Act 1973.
I APPLY for a Licence under the Dangerous Wild Animals Act 1976 in respect of which I enclose
the Fee of
(see licensing Fees and charges)
Date
/ /
Signed
Indicate capacity, if
signing on behalf of a
company or partnership.
Declaration
Data Protection
The information you supply will be used to enable this request or notification to be carried out and will be handled in
accordance with the Data Protection Act 1998. For more information please visit www.mansfield.gov.uk/privacy.
Mansfield District Council may wish to share the information you supply with other departments at the Council. If you do
not wish us to use the information you have supplied in this way please mark the box:
1921130872
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Form 0941130873: (Mansfield District Council)

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Completed 19 December 2020

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