"Health SPA Registration Renewal Form" - Delaware

Health SPA Registration Renewal Form is a legal document that was released by the Delaware Department of Justice - a government authority operating within Delaware.

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Download "Health SPA Registration Renewal Form" - Delaware

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STATE OF DELAWARE
OFFICE OF ATTORNEY GENERAL
Consumer Protection Unit
th
820 North French Street, 5
Floor
Wilmington, DE 19801
Phone: (302) 577-8600
http://attornerygeneral.delaware.gov/
RENEWAL YEAR ____________
HSR#_________
Health Spa Registration Renewal
In accordance with Title 6, Chapter 42 of the Delaware Code
1.
I am the owner or authorized agent of the following Delaware health spa:
____________________________________________________________________
(Name of Business)
____________________________________________________
(Street Address)
____________________________________________________
(
(City/State/Zip)
Phone Number)
2.
The information contained in our most recent submission to the Office of the
Attorney General remains accurate. I am aware of our ongoing obligation to notify the
Consumer Protection Unit of changes that would impact the status of these
representations. If information is inaccurate, I have provided the correct information in
an addendum attached to this renewal form.
[Complete either #3 or #4 – do not fill out both]
3.
This is our ___________ year of operations. I have registered and paid annual
fees
to
the
Health
Spa
Guaranty
Fund
in
year(s)
[list
prior
years]
__________________________________, for a total contribution of $_____________.
Since I have met 3 or more consecutive years of registration and payment of fees, I
hereby request a fee waiver for this year.
-1-
STATE OF DELAWARE
OFFICE OF ATTORNEY GENERAL
Consumer Protection Unit
th
820 North French Street, 5
Floor
Wilmington, DE 19801
Phone: (302) 577-8600
http://attornerygeneral.delaware.gov/
RENEWAL YEAR ____________
HSR#_________
Health Spa Registration Renewal
In accordance with Title 6, Chapter 42 of the Delaware Code
1.
I am the owner or authorized agent of the following Delaware health spa:
____________________________________________________________________
(Name of Business)
____________________________________________________
(Street Address)
____________________________________________________
(
(City/State/Zip)
Phone Number)
2.
The information contained in our most recent submission to the Office of the
Attorney General remains accurate. I am aware of our ongoing obligation to notify the
Consumer Protection Unit of changes that would impact the status of these
representations. If information is inaccurate, I have provided the correct information in
an addendum attached to this renewal form.
[Complete either #3 or #4 – do not fill out both]
3.
This is our ___________ year of operations. I have registered and paid annual
fees
to
the
Health
Spa
Guaranty
Fund
in
year(s)
[list
prior
years]
__________________________________, for a total contribution of $_____________.
Since I have met 3 or more consecutive years of registration and payment of fees, I
hereby request a fee waiver for this year.
-1-
4.
I have not registered and paid fees for 3 or more consecutive years. At this time,
we have __________ number of un-expired health spa contracts that cover periods longer
than 3 months. [The statutory fees, based upon the number of un-expired contracts, are:
$1,000 for less than 199 contracts; $2,000 for 200-499 contracts; $4,000 for 500-999
contracts; and, $8,000 for 1,000 contracts or more.] Since we have not paid fees to the
Health Spa Guaranty Fund for 3 or more consecutive years, our contribution to the Health
Spa Guarantee Fund for this year is $ ____________. A check for this amount made
payable to the “Health Spa Guaranty Fund” is enclosed.
5.
I declare that I am authorized to provide the representations herein on behalf of
____________________________________________, and have made a diligent and
(Name of Business)
reasonable investigation in order to verify and complete this annual registration renewal.
Name (Print): ______________________________________________
Signature: _________________________________________________
Title: _____________________________________________________
Date: _________________________ ____________________________
-2-
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