Notice of
Management Change
Section 231, Sale and Supply of Alcohol Act 2012
Please forward a copy of this completed form within two working days of appointment or termination to:
The Secretary Gore Police
Gore District Licensing Committee YX 10173
PO Box 8 Gore
Gore 9740 Attention: Alcohol Licensing
Licensed Premises Details:
Name of licensed premises:
Licensee:
Licence number:
Address of licensed premises:
Contact telephone: Contact fax:
Email address:
What are you notifying?
New Certificate Holding Manager
Full name: Effective from:
Certificate number: Expiry Date:
Temporary Manager (see s.229, Sale and Supply of Alcohol Act 2012)
Full name: Effective from:
Date of birth: Certificate number:
Residential address:
29 Civic Avenue, Gore
9710
PO Box 8, Gore 9740
Phone 03 209 0330
Fax 03 209 0357
Email info@goredc.govt.nz
www.goredc.govt.nz
Who are they replacing?
Reason:
Note that a temporary manager must apply for a manager’s certificate within 2 days of their appointmen t.
Acting Manager (see s.230, Sale and Supply of Alcohol Act 2012)
Full name: Effective from:
Date of birth: Certificate number:
Residential address:
Who are they replacing?
Reason:
Termination/Cancellation of Manager Appointment
Full name: Effective from:
Certificate number: Expiry Date:
Signature of Licensee: Date:
Name: Position:
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