Kirklees Council 

Local Government (Miscellaneous Provisions) Act 1982

& Hypnotism Act 1952

Application for Consent for an Exhibition, Demonstration or Performance of Hypnotism at a Place Licensed for Regulated Entertainment

Please Note: Hypnotism for the purpose of this application includes hypnotism, mesmerism and any similar act or process which produces or is intended to produce in any person any form of induced sleep or trance in which the susceptibility of the mind of that person to suggestion or direction is increased or intended to be increased, but does not include hypnotism, mesmerism or any such similar act or process which is self-induced.

1.	Name of person by whom the exhibition, demonstration or performance is to be given (‘the hypnotist’)

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2.	Address of Hypnotist:

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3.	Please give details of the last performances

(i)	Name of Venue …………………………………… Date……………………………………

(ii)	Name of Venue …………………………………… Date…………………………………………	

(iii)	Name of Venue …………………………………… Date………………………………………….

4.	Where is the exhibition, demonstration or performance of hypnotism taking place

Date / time

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5.	Please describe the nature of the proposed exhibition, demonstration or performance of hypnotism

(i)	If the performance includes hypnotising members of the public, will minders stay with
 hypnotised subjects during the show, including the interval? YES/NO

(ii)  Are you providing a minder for each hypnotised subject?	YES/NO

 (iii)  If the answer to (ii) is ‘no’ how many hypnotised subjects will a minder supervise?

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6.	(i) Have you ever been refused or had withdrawn a consent for hypnotism by any incensing authority? YES/NO

(ii) If YES please give details

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7. (i) Have you ever been convicted of an offence under the Hypnotism Act 1952 	YES/NO  

(ii) If YES please give details

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8. (i) Have you ever been convicted of an offence involving the breach of a condition regulating or prohibiting the giving of an exhibition, demonstration or performance of hypnotism? YES/NO

(ii) If YES please give details

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9. (i) Have you ever been barred from the Federation of Ethical Stage Hypnotists or the European Guild of Professional Stage Hypnotists or any other similar body? YES/NO

(ii) If YES please give details

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Signed: …………………………………………  Signed ……………………………………………..
(Hypnotist)	                                              (Licensee)

Dated: …………………………………………  Dated: …………………………………………….

Privacy Notice:

We have recently updated our Privacy Notice about how we use personal data provided to the Council. Further information can be found at: 
http://www.kirklees.gov.uk/beta/information-and-data/pdf/privacy-notice-other-licenses.pdf

Please return to: Investment and Regeneration Licensing Department, Flint Street Depo, Fint Street, Fartown, Huddersfield HD1 6LG Tel: 01484 456868 Fax: 01484456857

 
No such exhibition, demonstration or performance must take place without the written consent of Kirklees Council.