Part 4 – Declarations and Checklist (Please tick as appropriate)
I/ We confirm that, to the best of my/ our knowledge, the information contained in this
application is true. I/ We 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.
I/ We confirm that the applicant(s) have the right to occupy the premises.
Checklist:
Payment of the appropriate fee has been made/is enclosed
• A plan of the premises is enclosed
• The existing premises licence is enclosed
• The existing premises licence is not enclosed, but the application is
accompanied by –
• A statement explaining why it is not reasonably practicable to produce
the licence and,
• An application under the Section 190 of the Gambling Act 2005 for the
issue of a copy of the licence
• I/we understand that if the above requirements are not complied with the
application may be rejected
• I/ we understand that it is now necessary to advertise the application and give
the appropriate notice to the responsible authorities
Part 5 – Signatures
19. Signature of applicant or applicant’s solicitor or other duly authorised agent. If signing on behalf
of the applicant, please state in what capacity:
Signature:
Print Name:
Date: (dd/mm/yyyy) Capacity:
20. For joint applications, signature of 2nd applicant, or 2nd applicant’s solicitor or other authorised
agent. If signing on behalf of the applicant, please state in what capacity:
Signature:
Print Name:
Date: (dd/mm/yyyy) Capacity:
[Where there are more than two applicants, please use an additional sheet clearly marked
“Signature(s) of further applicant(s)”. The sheet should include all the information requested in
paragraphs 19 and 20.]
[Where the application is to be submitted in an electronic form, the signature should be generated
electronically and should be a copy of the person’s written signature.]
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signature
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signature
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