Application for Temporary Authority
(Section 136, Sale and Supply of Alcohol Act 2012)
General information:
A temporary authority is a temporary licence allowing the holder to operate off the existing base
licence for three months while they apply and are issued with a new (on or off) licence.
The application must be filed a minimum of 15 working days before possession or the commencement
of selling alcohol.
Please be sure all the questions are answered in full and all the appropriate documentation is
included. Incomplete applications will be delayed and maybe even returned.
At least two managers holding manager’s certificates must be employed on the premises before a
temporary authority can be issued.
Should that new licence not be issued in the three month period (for good reason) then a further
temporary authority may be considered provided the substantive licence application has at least been
filed with the DLC.
Application Checklist:
Supporting documents you need to provide with your application:
Application fee: $296.70
This is an application fee and is non-refundable after the application is received by
Matamata Piako District Council
A written statement from the owner of the building/property giving consent to the applicant for
alcohol to be sold or supplied on the premises (Note that the written consent must be for the
same party as detailed in the applicant section of this form)
Proof of title to the business sale and purchase agreement or lease (financial details can be
excluded). A complete list of food and non/low alcoholic beverages provided (menu)
A current floor plan of the premises
A draft of your proposed Host Responsibility Policy
Copies of each current manager’s certificate for those nominated to manage the premises
Copies of any other licences held by the applicant (if applicable)
If you are applying for the temporary authority on behalf of someone else, you must also
A copy of the authority to act as an agent of the applicant, signed by the applicant
Fee due: $296.70
Send the completed application form and attachments to:
Liquor Licensing Department
Matamata-Piako District Council
PO Box 266
Te Aroha, 3342
Application for Temporary Authority
(Section 136, Sale and Supply of Alcohol Act 2012)
To the Secretary
District Licensing Committee, Matamata Piako District Council
Application for temporary authority to carry on the sale and supply (or delivery) of alcohol is made
in accordance with the details set out below.
Applicant details
Full legal name to appear on licence:
(the licensee, i.e. the person or organisation that the proceeds from alcohol sales are going to):
Date of birth (if the applicant is an individual):
Occupation (if the applicant is an individual):
Postal address (for service of documents):
_____________________________________________ _ Postcode:
Home phone:___________________________ Work phone:
Mobile phone: E-mail address:
Daytime contact details (if different from above):
Phone number: _________________________ Mobile number:
E-mail address:
Does the applicant (or any company directors) have any criminal convictions?
Yes No
(other than convictions for offences against provisions of the Land Transport Act 1998 not contained
in Part 6, and offences to which the Criminal Records (Clean Slate) Act 2004 applies).
If YES, please state the nature of the offence, date of conviction and penalty suffered:
Nature of the offence
Date of conviction
Penalty suffered
If the applicant is a company, state the date and place of incorporation:
If the applicant is a company, state the details of each director:
Date of birth
Place of birth
Existing licence details
Type of Licence: On Off
Licence number:
Premises details
Address of licensed premises:
Proposed trading name:
Previous trading name (if different from above):
Application details
What right, title, estate, or interest does the applicant have in the premises and business (or
conveyance) to which the application relates?
On what date does the applicant intend to take over ownership of the business?
Does the applicant intend to carry on the sale and supply (or delivery) of alcohol personally?
Yes No
If NO, what is the full legal name, address, and occupation of the person through whom the applicant
intends to carry on the sale and supply (or delivery) of alcohol?
What are the reasons for the application?
What relevant experience and training does the applicant have regarding the sale and supply of
Duty managers’ details. State the full details of each manager or proposed manager:
Certificate number
Expiry date
The New Zealand police are required by the Sale and Supply of Alcohol Act 2012 to make inquiries
into the suitability of the applicant. This will involve informing the District Licensing Committee and the
Alcohol Regulatory and Licensing Authority of any convictions or concerns involving the applicant.
Should there be any concerns, the applicant will also be informed.
I consent to the release of this information
I hereby state that the above particulars are true and correct
I understand that my application will not be lodged with Council until the application fee is paid
and all required documents are supplied. Incomplete applications will be returned.
Applicant name: Designation:
Signature: ___________________ ______ Date:
Contact us:
Phone: (07) 884 0060
E-mail: customerservices@mpdc.govt.nz
Website: www.mpdc.govt.nz/our-services/alcohol-licensing
Location: 35 Kenrick Street, Te Aroha
The personal information that you provide on this form will be held and protected by Matamata Piako
District Council in accordance with our Privacy Statement (available at
https://www.hamilton.govt.nz/privacy and at our libraries, pools and the Municipal Building, Garden
Place) and with the Privacy Act 1993. The Privacy Statement explains how we can use and share
your personal information in relation to any interaction you have with the Council, and how you can
access and correct that information. You should familiarise yourself with this Statement before
submitting this form.