APPLICATION FOR TANNING FACILITIES REGISTRATION …

PHSS-1 AUG 16 Page 1 of 2 STATE USE ONLYNew Jersey Department of HealthConsumer, Environmental and Occupational Health ServicePublic Health and Food Protection ProgramPO Box 369 Trenton, NJ 08625-0369 APPLICATION FOR TANNING FACILITIES REGISTRATION (AUTHORITY: 26:2D-81 et seq., particularly 26:2D-88)Amount Rec d:$_____ Certified Check #_____ Money Order#_____Date:_____/_____/_____Transmi ttal No.#_____Registration Status: Initial REGISTRATION annual Renewal REGISTRATION Change of REGISTRATION InformationThe APPLICATION for REGISTRATION shall be accompaniedby a single certified check ( , cashiers check) ormoney order, and shall be made payable to Treasurer, State of New Jersey. Personal checks shall not be SCHEDULEI nitial REGISTRATION or annual Renewal REGISTRATION :$ (includes first ten sunlamp products) plus $ for eachadditional sunlamp product over the first of REGISTRATION Information:No fee required$ + [$ x (number of sunlamp products >10)] = $ Instructions:For Initial REGISTRATION : Complete all information requested on this APPLICATION annual Renewal REGISTRATION : Update the Initial REGISTRATION APPLICATION with any new or corrected Change of REGISTRATION Information: Update the Initial REGISTRATION APPLICATION with any new or corrected INFORMATIONName of TANNING

Transmittal No. #_____ Registration Status: Initial Registration Annual Renewal Registration Change of Registration Information The Application for Registration shall be accompanied by a single certified check (i.e., cashiers check) or money order, and shall be made payable to “Treasurer, State of New Jersey.”

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