Free Application for Registration of Tanning Devices, DPH 7337 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7337 (Rev. 08/06)

STATE OF WISCONSIN 255.08, Wis. Stats Completion of this form is required under the provisions of s.255.08 & s.73.0301(1)(d)3.

APPLICATION FOR REGISTRATION OF TANNING DEVICES
FOR OFFICE USE ONLY
County____________________________ Registration No.____________________________

Information collected on this form will be used to process the application for registration.

Business Name

FEIN Number or Social Security Number

Business Address-Street, City, State, Zip

Mailing Address if Different than Business Address. Telephone No. and Extension ( ) Name & Title of Person Responsible Number of Tanning Devices Brand Name of Each Device and Model No. Device Model No.

Device

Model No.

Primary Type of Business ­ Tanning, Cosmetology, Health Fitness, etc. If you are responsible for units at locations other than the address listed above, please list the locations.

SIGNATURE - Person Responsible
Complete form and mail original copy and fee to: Make check in the amount of $10.00 payable to the Department of Health and Family Services. Keep a copy of the completed signed and dated form for your records.

Title

Date Signed (mm/dd/yy)
Department of Health & Family Services Division of Public Health Tanning Device Registration, RM B157 P. O. Box 2659 Madison, WI 53701-2659

Note: Multiple tanning devices at a single location and under the control of one person may be considered a single registration and only one registration fee is required. If, however, the devices are located at separate addresses, it will be necessary to consider each location as a separate registration and an additional fee is required for each location. All permits expire on June 30 regardless of issue date. Personally Identifiable information on this form will only be used to obtain relevant data required by the provisions of s.73.0301(1)(d)3 and s.255.08.