334 



ACT 39 AND 40 VIC. C. 77 



APPLICATION FOR LICENCE. 



Address 



Date 



To the Right Honourable the Secretary of State 

 for the Home Department. 



Sir, 



* Here insert I * 



name and profes- 

 sion (see Sec. 11 

 of Act) of Appli- 

 cant. — 



beg to apply under the above-mentioned Act for a Licence 

 regis^ered^face. f° r the performance of experiments on animals. 



If the place is 

 not registered, it 

 will be necessary 



having authority P* ace m which it is proposed that the experiments are 

 tofetofe t0 be Performed is t 



Secretary of 

 State for its 

 registration. 



1 Here insert a The experiments which it is proposed to perform are } 



general descrip- 

 tion of proposed 

 experiments and 



their object; also 



state, if that is 

 the case, the in- 

 tention of Appli- 

 cant to send in a 



certificate or cer- 

 tificates (describ- 

 ing each certiti- 



cate by its 

 appropriate 

 letter) with 



reference to the 



same experi- 

 ments, or any 

 other circum- 

 stances that may ■ 



be material. See 

 also Note at the 

 end of the 



application. « 



