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Guildford Borough Council (Guildford Borough Council)

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Guildford Borough Council
Disclosure of convictions and civil immigration penalties and declaration
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 may wish to keep a copy of the completed form for your records.
1. Your personal details
TITLE Please tick
Mr Mrs Miss Ms Other (please state)
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 Please tick
Mr Mrs Miss Ms Other (please state)
Surname
Forenames
2. Forfeiture by a court or revocation by a licensing authority of a personal
licence in the last 5 years
Please tick
Has any personal licence held by you been forfeited or revoked in the
last 5 years?
If yes, please provide details below:
Yes
No
2
3. Relevant or foreign offences and 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 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 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:
3
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
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 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
4
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.
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Completed 26 December 2020

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