Hairdressers Premises Licence
Application Form
Please return this form to: or Ashburton District Council, PO Box 94, Ashburton 7740
Applicant Details
Trading Name:
Postal Address:
Phone Number:
Signature and Date
I hereby make an application for a Hairdressers Premises Licence under the Health (Registration of
Premises) Regulations 1966 and the Health (Hairdressers) Regulations 1980.
I have also enclosed a fee of $________
Signed: _____________________________ Name: _________________________________
Office Use Only:
Fee received Yes No Date Issued:
Receipt issued Yes No Certificate Number:
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