Application for a premises licence under the Gambling Act 2005 (vessel)
PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST
If you are completing this form by hand, please write legibly in block capitals using ink. Use
additional sheets if necessary (marked with the number of the relevant question). You may wish to
keep a copy of the completed form for your records.
Applications in respect of premises which are not a vessel should be made on the relevant form for
that type of premises.
Part 1 – Type of premises licence applied for
Regional Casino Large Casino Small Casino
Bingo Adult Gaming Centre Family Entertainment Centre
Do you hold a provisional statement in respect of the premises? Yes No
If the answer is “yes”, please give the unique reference number for the provisional statement (as
set out at the top of the first page of the provisional statement):
Part 2 – Applicant Details
If you are an individual, please fill in Section A. If the application is being made on behalf of an
organisation (such as a company or partnership), please fill in Section B.
1. Title: Mr
Mrs Miss Ms Dr Other (please specify)
2. Surname: Other name(s):
[Use the names given in the applicant’s operating licence or, if the applicant does not hold an
operating licence, as given in any application for an operating licence]
3. Applicant’s address (home or business – [delete as appropriate]
4(a) The number of the applicant’s operating licence (as set out in the operating licence):
4(b) If the applicant does not hold an operating licence but is in the process of applying for one,
give the date on which the application was made:
5. Tick the box if the application is being made by more than one person.
[Where there are further applicants, the information required in questions 1 to 4 should be included
on additional sheets attached to this form, and those sheets should be clearly marked “Details of