APPLICATION FORM FOR CLUB GAMING PERMIT OR CLUB MACHINE
PERMIT
(FOR USE
BY
APPLICANTS - MEMBERS' CLUBS, COMMERCIAL CLUBS AND MINERS'
WELFARE INSTITUTES)
If
you
are
completing
this
form
by
hand,
please
write
legibly
in
block
capitals
using
ink.
To:
Official
use
only
- licensing authority logo
or
symbol
[insert
name
and
address
of
relevant licensing
authority-
this
is
the authority in whose area
the premises relating
to
this application are
wholly
or
partly situated]
SECTION
A-Type
of
Application
1.
Please indicate type of application by ticking one of the boxes below:
D
Application
for
a
club
gaming
permit
D
Application
for
a
club
machine
permit
D
Application
to
renew
a
club
gaming
permit
D
Application
to
renew
a
club
machine
permit
SECTION B -
Existing
registration
under
Gaming
Act
1968
[To be completed
if
the applicant wishes
to
apply
as
an existing
Part
2
or
Part
3 operator.
Do
not
complete
if
applying
to
renew a permit]
Part
I
1.
Did the applicant have a Part 2 or Part 3 Registration under the Gaming Act 1968 that had
effect on
31
st August 2007? Yes D No D
Part
II
-
Complete
if
the
answer
to
question
1
is
'Yes':
2.
Please indicate the date on which the registration was due to expire (i.e. the date
it
was fixed to
expire when the registration was granted or last renewed)
3.
Is
the date given in answer to question 2 a date after
31
st August 2007? Yes D No D
4.
If the answer to question 3 is 'No', was the applicant's registration renewed on or after 1
st
September 2007? Yes D No D
Please give date of renewal
Part
Ill -
Complete
if
the
answer
to
question
1
is
'NO':
5.
Was the applicant first registered under Part 2 or Part 3 of the Gaming Act 1968
on
or after 1 st
September 2007? Yes
D No D
Please give date of first registration
Part
IV
6.
If the answer to either question 1 or 5 is 'Yes', please indicate which type of registration:
Part 2 Registration
D Part 3 Registration D
7.
Does this application relate to the same (or substantially the same) premises as those to which
the registration relates? Yes
D No D
8.
Is
this application made before the 'relevant date'? Yes D No D
[The 'relevant date'
is
the date on
which
the registration
is
due
to
expire,
except
where
the
applicant
is
registered
for
the first time
on
or
after
1
sf
September
2007,
or
the registration
is
renewed
on
or
after
that date. In those circumstances, the 'relevant date' is:
(a)
for
a
Part
2 registration, (in a
first
registration case) the
last
day
of
the
period
of
one
year
beginning on the date
of
registration,
or
(in a
renewal
case) the
last
day
of
the
period
of
ten
years
beginning on the date
of
renewal;
(b)
for
a
Part
3 registration, the
last
day
of
the
period
of
5
years
beginning
on
the date
of
registration
or
renewal.]
The
applicant
may
apply
as
an
existing
operator
if:
(a)
the
answer
to
questions
1,
3, 7
and
8 is
'Yes'
OR
(b)
the
answer
to
questions
1,
4,
7
and
8
is
'Yes'
OR
(c)
the
answer
to
questions
5, 7
and
8 is
'Yes'
AND
-
the
answer
to
question
6
is
'Part
2
Registration'
and
the
applicant
is
applying
for
a
club
gaming
permit;
OR
-
the
answer
to
question
6
is
'Part
3
Registration'
and
the
applicant
is
applying
for
a
club
machine
permit.
If
the
applicant
is
applying
as
an
existing
operator:
Do
NOT
complete
SECTION C
Relevant
documentation
must
be
provided
-
see
SECTION H
A
different
application
fee is
payable
for
an
existing
operator.
SECTION C -
Fast-track
Procedure
[This section does
not
apply
to
Scotland]
9.
Please indicate if this application is made under the fast-track procedure [tick
as
appropriate]:
Yes D No D [to
apply
under
the fast-track procedure, the applicant
must
be
the
holder
of
a club
premises
certificate
under
section 72
of
the Licensing
Act
2003]
10. If the answer to question 9 is 'Yes', please complete the declaration below:
'I
hereby
certify
that
the applicant
for
a
permit
is
the
holder
of
a club
premises
certificate
under
section 72
of
the Licensing
Act
2003'
Full Name
Signature
Capacity
If
the
answer
to
question
9 is
'Yes'
relevant
documentation
must
be
provided
- see
SECTION H
SECTION D - Details
of
the
Applicant
11. Name
of
applicant
12. Address (including postcode) of premises
on
which the applicant operates
[any
gaming
or
gaming machines authorised
by
a relevant
permit
must
take place
or
be located on
these premises]
SECTION E -
Information
about
the
Applicant
If
the
applicant
is
a
miners'
welfare
institute,
complete
questions
13
to
16:
13.
Is
the applicant established and conducted for social and recreational purposes?
Yes
D No D
14. Are the applicant's affairs managed by a group of individuals of whom at least two thirds are
miners' representatives? Yes
D No D
15. Does the applicant operate on premises the use of which is regulated in accordance with a
charitable trust? Yes
D No D
16. If the answer to question 15 is 'Yes', has the charitable trust received money from any of the
following:
(a) the Miners' Welfare Fund established by section 20
of
the Mining Industry Act 1920,
(b) the former body corporate which was known
as
the Coal Industry Social Welfare Organisation
and incorporated under the Companies Act 1948, or
(c) the charitable trust known as the Coal Industry Social Welfare Organisation?
Yes
D No D
If
the
applicant
is
a
members'
club
or
commercial
club,
complete
questions
17
to
22
17.
Is
the applicant established with the purpose of functioning only for a
Ii
mited period of time?
Yes
D No D
18. Does the applicant have at least 25 individual members? Yes D No D
19.
Is
the applicant established and conducted for the benefit of its members? Yes D No D
20.
Is
the applicant established or conducted
as
a commercial enterprise? Yes D No D
21. Describe the purpose(s) for which the applicant is wholly or mainly established and conducted
22. If the applicant is established or conducted wholly or mainly for the purpose of the provision of
facilities for gaming, please specify the kinds
of
gaming
SECTION F - General
information
about
person
completing
this
application
form
on
behalf
of
applicant
23. Name
24. Capacity
25. Address (including postcode)
SECTION G -
Contact
details
for
correspondence
associated
with
this
application
26. Please tick one box as appropriate:
Address in section D
D Address in section F D Address below D:
Address (including postcode)
Telephone number
E-mail address (if the applicant is happy for correspondence
in
relation to this application to be
sent via e-mail)
SECTION H -
Declaration
27. Please complete the following declarations and checklist:
I [full
name]
a.
make this application
on
behalf of the applicant and have authority to act on behalf
of
the
applicant.
b.
confirm that I am aware of any relevant provision
of
a code
of
practice issued
by
the Gambling
Commission under section 24 of the Gambling Act 2005 about the location and operation
of
a
gaming machine.
c.
confirm that I am aware that the permit to which this application relates will be subject to the
relevant conditions specified
in
section
271
or 273 of the Gambling Act 2005.
d.
confirm that I am aware that (unless this application is made under the fast-track procedure) the
applicant must send a copy of this application and any accompanying documents to the Gambling
Commission and the chief officer of police (or chief constable
in
Scotland) within a period
of
seven
days beginning
on
the date this application is made.
e.
confirm
that,
to
the
best
of
my
knowledge,
the
information
contained
in
this
application
is
true.
I
understand
that
it
is
an
offence
under
section
342
of
the
Gambling
Act
2005
to
give
information
which
is
false
or
misleading
in,
or
in
relation
to,
this
application.
Checklist [tick
as
appropriate]:
D Payment
of
the appropriate fee
of£
is enclosed.
D A copy of the existing club gaming permit
or
club machine permit is enclosed [only applies
to
applications
to
renew a permit]
D A copy of the registration certificate issued under Part 2
of
the Gaming Act 1968 is enclosed
[only applies
if
the applicant wishes
to
apply
as
an existing
Part
2 operator]
D A copy of the registration certificate issued under Part 3
of
the Gaming Act 1968 is enclosed
[only applies
if
the applicant wishes
to
apply
as
an existing
Part
3 operator]
D The applicant's club premises certificate issued under section 72
of
the Licensing Act 2003 is
enclosed [only applies
if
the applicant has completed the declaration in section
CJ
Signature
Date
Capacity
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