Application
for
a
premises
licence
under
the
Gambling
Act
2005
(standard
form)
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.
Where the application
is-
In
respect of a vessel, or
To convert an authorisation granted under the Betting, Gaming and Lotteries Act 1963 or
the Gaming Act 1968,
the application should be made on the relevant form for that type
of
premises or application.
Part
1 -
Type
of
premises
licence
applied
for
Regional Casino D Large Casino D Small Casino D
Bingo D
Adult Gaming Centre D Family Entertainment Centre D
Betting (Track) D Betting (Other) D
Do
you hold a provisional statement
in
respect
of
the premises? Yes D No D
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 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.
Section
A
Individual
applicant
1.
Title:
Mr
D Mrs D Miss D Ms D Dr D 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]):
Postcode:
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. D
[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
further applicants".]
Section B
Application on behalf
of
an
organisation
6.
Name
of applicant business or organisation:
[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.]
7.
The
applicant's registered or principal address:
Postcode:
8(a) The
number
of
the applicant's operating licence
(as
given in the operating licence):
8(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:
9.
Tick
the
box
if
the
application is being
made
by
more than one organisation. D
[Where there are further applicants, the information required in questions 6
to
8 should be included
on additional
sheets attached to this form,
and
those
sheets
should be clearly marked "Details
of
further applicants".]
Part
3 - Premises Details
10. Proposed trading
name
to
be
used
at
the
premises (if known):
11. Address of the premises (or,
if
none,
give
a description
of
the
premises and
their
location):
Postcode:
12. Telephone
number
at premises (if known):
13. If the premises are
in
only a part of a building, please describe the nature of the building (for
example, a shopping centre or office block). The description should include the number of floors
within the building and the floor(s) on which the premises are located.
14(a) Are the premises situated in more than one licensing authority area?
Yes/No [delete
as
appropriate]
14(b). If the answer to question 14(a) is yes, please give the names of all the licensing authorities
within whose area the premises are partly located,
other
than
the
licensing
authority
to
which
this
application
is
made:
Part
4 -
Times
of
operation
15(a). Do you want the licensing authority to exclude a default condition so that the premises
may
be used for longer periods than would otherwise be the case? Yes/No [delete as appropriate]
[Where the relevant kind
of
premises licence
is
not
subject
to
any
default conditions, the answer to
this question will be no.]
15(b). If the answer to question 15(a) is yes, please complete the table below to indicate the times
when you
want
the premises to be available for use under the premises licence.
Start
Finish Details
of
any seasonal variation
Mon hh:mm hh:mm
Tue
Wed
Thurs
Fri
Sat
Sun
16. If you wish to apply for a premises licence with a condition restricting gambling to specific
periods in a year, please state the periods below using calendar dates:
Part
5 -
Miscellaneous
17. Proposed commencement date for licence (leave blank
if
you want the I icence to commence
as
soon as
it
is issued): (ddlmmlyWY)
18(a). Does the application relate to premises which are part
of
a track
or
other sporting venue
which already has a premises licence? Yes/No [delete
as
appropriate]
18(b). If the answer to question 18(a) is yes, please confirm by ticking the box that an application to
vary the main track premises licence has been submitted with this application.
D
19(a). Do you hold any other premises licences that have been issued by this licensing authority?
Yes/ No [delete as appropriate]
19(b). If the answer to question 19(a) is yes, please provide full details:
20. Please set out any other matters which you consider to be relevant to your application:
Part
6 -
Declarations
and
Checklist
(Please
tick)
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
D
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.
D
Checklist:
Payment
of
the appropriate fee has been made/is enclosed D
A plan
of
the premises is enclosed D
I/
we understand that if the above requirements are not complied with the D
application may be rejected
I/
we understand that it is now necessary to advertise the application and give D
the a
ro
riate notice to the res onsible authorities
Part 7 - Signatures
21. 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: (ddlmmlyyyy) Capacity:
22. 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: (ddlmmlyyyy) Capacity:
[Where there are more than
t\No
applicants, please
use
an additional
sheet
clearly marked
"Signature(s)
of
further app/icant(s)". The
sheet
should include all the information requested in
paragraphs 21 and 22.]
[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.]
Part 8 - Contact Details
23(a) Please give the name of a person who can be contacted about the application:
23(b) Please give one or more telephone numbers at which the person identified
in
question 23(a)
can be contacted:
24. Postal address for correspondence associated with this application:
Postcode:
25. If you are happy for correspondence
in
relation to
your
application to be sent via e-mail, please
give the e-mail address to which you would like correspondence to be sent:
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome