Fillable Form Ref: LA03/PA20: CHANGE OF NAME AND/OR ADDRESS (North Devon Council)

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Form Ref: LA03/PA20: CHANGE OF NAME AND/OR ADDRESS (North Devon Council)

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The Licensing Team
Environmental Health & Housing
North Devon Council
PO BOX 379, Barnstaple, Devon,
EX32 2GR
Contact Details:
Tel: 01271 388870
Email:licensing@northdevon.gov.uk
Web:www.northdevon.gov.uk/licensing
NOTIFICATION FOR PERSONAL ALCOHOL LICENCE HOLDER
CHANGE OF NAME AND/OR ADDRESS
Form Ref: LA03/PA20
Privacy Notice – privacy & data protection
North Devon Council, the Data Controller, collects personal information when you contact us
for the licensing services we provide. We will use this information to provide these services,
such as the granting of a licence, permit, registration or receipt of a notice.
We may need to share your information with other departments in North Devon Council or
external/ third parties, where this is necessary to perform our public functions & services as
provided by law.
For more information as a Data Subject regarding privacy & data protection, including how we
manage your personal information, data retention and your rights, please see our Privacy
Notice on the website: www.northdevon.gov.uk/privacy
If you require this document in an alternative format, please contact
us.
PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST
If you are completing this form by hand, please write legibly in block capitals. In all
cases ensure that your answers are inside the boxes and written or typed in black
ink. Use additional sheets if necessary. You should keep a copy of the completed
form for your records.
- 1 - LA03/PA20/06.18
–
–
NOTIFICATION FOR PERSONAL ALCOHOL LICENCE HOLDER CHANGE OF
NAME AND/OR ADDRESS
The Licensing Act 2003 (Personal Licences) Regulations 2005,
Regulation 8
Part 1
Your Old Personal Details
(as shown on your Personal Licence)
Title: Mr Mrs Miss Ms Dr Other (please specify)
Surname
Forenames
Address (as shown on your Personal Licence)
Post Town Postcode
Your Personal Licence Number
Your New Name
(if you have not changed your name please cross through this section)
Title: Mr Mrs Miss Ms Dr Other (please specify)
Surname
Forenames
Your New Address
(if you have not changed your address please cross through this
section)
Post Town Postcode
TELEPHONE NUMBERS Daytime
Evening
Mobile
Fax Number
E-mail address:
Part 2
Address for correspondence associated with this application
(if different to
the address above)
Post Town Postcode
TELEPHONE NUMBERS Daytime
Evening
Mobile
Fax Number
E-mail address (if you would prefer us to correspond with you by e-mail)
- 2 - LA03/PA20/06.18
–
–
Part 4
Checklist
Please tick √
•
I have enclosed my NDDC Personal Alcohol Licence
•
I have enclosed my NDDC Personal Alcohol Licence Badge
•
I have enclosed payment of the appropriate fee (£10.50)
(make cheques payable to North Devon Council)
Part 5
Declaration
The information contained in this form is correct to the best of my knowledge and
belief.
It is an offence knowingly or recklessly to make a false statement in or in connection with an
application for the grant or renewal or change of address of a Personal Alcohol Licence. (A
person is to be treated as making a false statement if they produce, furnish, sign or
otherwise make use of a document that contains a false statement). To do so could result in
prosecution and a fine not exceeding level 5 on the standard scale [£5000].
Signature:
Date:
- 3 - LA03/PA20/06.18
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Form Ref: LA03PA20: CHANGE OF NAME ANDOR ADDRESS (North Devon Council)

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Completed 16 December 2020

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