Application for Waiver or Exemption
Sale and Supply of Alcohol Act 2012
2. Type of Waiver or Exemption Requested
Queen Street, P O Box 404, Te Kuiti 3941, NZ. Telephone 07-878 0800, Fax 07-878 7771, Email email@example.com, Website www.waitomo.govt.nz
Applicants Full Legal Name
Type of application to which waiver or exemption relates
Section 137 : Special Licence Application led within 20 working days of the event to which it relates
Section 213 : Request for exemption to appoint a nominated person in place of a certicated manager in respect
to a special licence
Section 127(2) : Licence Renewal Application led within 20 working day of licence expiry
Section 208 : Other neglect or omission, namely
Please Note: Waivers and exemptions are at the discretion of the District Licensing Committee, and can only be
granted in circumstances which are allowed by the Act. They are not automatic.
An applicant should plan on the basis that the request has not been approved until advised otherwise.
Signed for the Applicant Date