Fillable Form Ref: LA03/PA8: DISCLOSURE OF CONVICTIONS AND DECLARATION (North Devon Council)

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Form Ref: LA03/PA8: DISCLOSURE OF CONVICTIONS AND DECLARATION (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
DISCLOSURE OF CONVICTIONS AND DECLARATION
Form Ref: LA03/PA8
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
Before completing this form please read the guidance notes at the end of the form. 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/PA8/06.18
–
–
–
DISCLOSURE OF CONVICTIONS AND CIVIL IMMIGRATION PENALTIES AND
DECLARATION
Part 1
Your personal de
tails
Title: Mr Mrs Miss Ms Dr Other (please specify)
Surname
Forenames
PREVIOUS NAMES (if relevant) Please enter details of any previous names or maiden
names. Please continue on a separate sheet if necessary)
Title: Mr Mrs Miss Ms Dr Other (please specify)
Surname
Forenames
Part 2
Forfeiture
of a per
sonal
licence in the last 5 years
Has any personal licence held by you been forfeited or revoked in the last 5
years?
Yes No
If yes, please provide details below:
Name of court/licensing
authority
Address of court
Date of forfeiture/revocation
Offence which resulted in the
forfeiture/revocation
Any additional details
Part 3
Relevant or foreign offences
an
d civil immigration penalties
Read note 1
Please tick √
Have you been convicted of any relevant offence or foreign offence or been
required to pay a civil immigration penalty?
Yes No
If you have been convicted of any relevant offence you must provide details for each
conviction of the date of conviction, the name and location of the convicting court, offence of
which you were convicted and the sentence imposed:
If you have been convicted of any foreign offences you must provide details for each
conviction of the date of conviction, the name and location of the convicting court, offence of
which you were convicted and the sentence imposed:
- 2 - LA03/PA8/06.18
–
–
Part 4
Declaration
I declare
that I have not been convicted of any relevant offence or any foreign offence
or been required to pay a civil immigration penalty
Signature:
Date:
Part 5
Declaration
The information contained in this for
m 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 of a personal licence. A person is to be treated as
making a false statement if he produces, furnishes, signs or otherwise makes use of a
document that contains a false statement. To do so could result in prosecution and a fine of
any amount. It is an offence under section 24B of the Immigration Act 1971 to work illegally.
Signature:
Date:
NOTES
1. Relevant or foreign offences
Relevant offences are the offences listed in Schedule 4 to the Licensing Act 2003:
The meaning of foreign offence is dealt with in section 113 of the Licensing Act
2003.
If you are the holder of a justices’ licence and you are applying for a personal licence
under regulation 8 of the Licensing Act (Personal licences) Regulations 2005 see
paragraphs 23 and 28 in Part 3 of Schedule 8 to the Licensing Act 2003 for the
information you are required to give.
If you are convicted of any relevant or foreign offence during the period between
when your application is made and when your application is determined or
withdrawn, you must notify the authority to which your application was made. Failure
to do so without reasonable excuse could lead to prosecution and a fine not
exceeding level 4 on the standard scale.
2. Civil immigration penalty
An Immigration penalty means a penalty under either section 15 of the Immigration,
Asylum and Nationality Act 2006 or section 23 of the Immigration Act 2014.
- 3 - LA03/PA8/06.18
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Form Ref: LA03PA8: DISCLOSURE OF CONVICTIONS AND DECLARATION (North Devon Council)

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Completed 16 December 2020

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