NEW CERTIFICATE HOLDING MANAGER
TEMPORARY MANAGER
(see s.229, Sale and Supply of Alcohol Act)
ACTING MANAGER (see s.230, Sale and Supply of Alcohol Act)
TERMINATION/CANCELLATION OF MANAGER APPOINTMENT
Company Name: Premise Name:
Licence Number:
Address of Licensed Premises:
Contact Name:
Contact Phone: ( ) Contact Fax: ( )
Signature of licensee: Date:
Name: Position (director, partner etc):
Full Name: Effective from: / / 20
Certicate Number: Certicate Expiry Date:
Date of Birth:
Effective from: / / 20 to / / 20
Full Name: Date of Birth:
Residential Addresss:
Who they are replacing: Certicate Number:
Reason:
NOTE that a temporary manager must apply for a manager’s certicate within two working days of their appointment.
Effective from: / / 20 to / / 20
Full Name: Date of Birth:
Residential Addresss:
Who they are replacing: Certicate Number:
Reason:
Full Name: Effective from: / / 20
Certicate Number: Certicate Expiry Date:
Date of Birth:
New Zealand Police The Secretary
Liquor Licensing Sergeant District Licensing Committee
DX Box ZX10323 Private Bag 50072
11 Camp Street, QUEENSTOWN 9300 10 Gorge Road, QUEENSTOWN 9300
Email: queenstown.licensing@police.govt.nz Email: services@qldc.govt.nz
WHAT ARE YOU NOTIFYING? (Please tick and complete the applicable box below)
FORWARD A COPY OF THIS COMPLETED FORM, within two working days of the appointment (or termination), to:
Page 1/1 // January 2015
NOTICE OF
MANAGEMENT CHANGE
Section 231, Sale and Supply of Alcohol Act 2012
click to sign
signature
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