Notification of an Interest In Premises The Licensing Act 2003 (Premises Licence and Club Premises Certificate) Regulations 2005. Regulation 9/Schedule 1

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Notification Interest In Premises

Notification of an Interest In Premises

This form can be completed on-line.

Before completing this form please read the guidance notes below. Use additional sheets if necessary. You may wish to keep a copy of the completed form for your records.

Guidance Notes

1. The application form must be signed.

2. A notifier?s agent (for example solicitor) may sign the form on their behalf provided that they have actual authority to do so.

3. Where there is more than one notifier, with either Notifiers or their respective agents must sign the application form.

4. This is the address that we shall use to correspond with you about this application.

The fee for this application is £21 and must be included with the submission of the application.

Once PRINTED please ensure the form is signed and sent to the Council

Schedule 1: Notification of an interest in premises under section 178 of the Licensing Act 2003

Enter Notifiers Name

I/We

Title mandatory field

Forenames mandatory field

Surname mandatory field

Email mandatory field

hereby give/gives notice of my/our interest in the premises identified below for the purpose of section 178 of the Licensing Act 2003.

Part 1 - Premises details

Postal address of premises or if none, ordnance survey map reference or description

Premise Name mandatory field

Address Line 1 mandatory field

Address Line 2

Town / Village mandatory field

County

Postcode mandatory field

Ordinance Survey Reference

Description of address

Phone mandatory field

Name of the 'APPLICANT for' OR 'HOLDER of' premises licence, or club applying for or holding, club premises certificate (if known)

Title/Club

Forenames (or Clubname)

Surname (leave blank if Clubname)

Premises Licence Number or Club Premises Certificate Number (if known)

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