The Royal Borough of Greenwich
Licensing Department, Floor 4 The Woolwich Centre,
35 Wellington Street, London, SE18 6HQ
Tel: 020 8921 8018 | Email:
licensing@royalgreenwich.gov.uk
Application for the review of a premises licence or club
premises certificate under the Licensing Act 2003
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 in black ink. Use
additional sheets if necessary.
You may wish to keep a copy of the completed form for your records.
I
(Insert name of applicant)
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Part 1 Premises or club premises details
Postal address of premises or, if none, ordnance survey map reference or
description
Post town
Post code (if known)
Name of premises licence holder or club holding club premises certificate (if
known)
Number of premises licence or club premises certificate (if known
Part 2 - Applicant details
I am
Please tick yes
1) an interested party (please complete (A) or (B) below)
a) a person living in the vicinity of the premises
b) a body representing persons living in the vicinity of the premises
c) a person involved in business in the vicinity of the premises
2
d) a body representing persons involved in business in the vicinity of the
premises
2) a responsible authority (please complete (C) below)
3) a member of the club to which this application relates (please complete (A)
below)
(A) DETAILS OF INDIVIDUAL APPLICANT (fill in as applicable)
Please tick
Mr
Mrs
Miss
Ms
Other title
(for example, Rev)
Surname
First names
Please tick yes
I am 18 years old or over
Current postal
address if
different from
premises
address
Post town
Post Code
Daytime contact telephone number
E-mail address
(optional)
(B) DETAILS OF OTHER APPLICANT
Name and address
Telephone number (if any)
E-mail address (optional)
3
(C) DETAILS OF RESPONSIBLE AUTHORITY APPLICANT
Name and address
Telephone number (if any)
E-mail address (optional)
This application to review relates to the following licensing objective(s)
Please tick one or more boxes
1) the prevention of crime and disorder
2) public safety
3) the prevention of public nuisance
4) the protection of children from harm
Please state the ground(s) for review (please read guidance note 1)
4
Please provide as much information as possible to support the application
(please read guidance note 2)
5
Please tick yes
Have you made an application for review relating to this premises before
If yes please state the date of that application
Day
Month
Year
If you have made representations before relating to this premises please state
what they were and when you made them
6
Please tick yes
I have sent copies of this form and enclosures to the responsible
authorities and the premises licence holder or club holding the club
premises certificate, as appropriate
I understand that if I do not comply with the above requirements
my application will be rejected
IT IS AN OFFENCE, LIABLE ON CONVICTION TO A FINE UP TO LEVEL 5 ON
THE STANDARD SCALE, UNDER SECTION 158 OF THE LICENSING ACT 2003
TO MAKE A FALSE STATEMENT IN OR IN CONNECTION WITH THIS
APPLICATION
Part 3 Signatures (please read guidance note 3)
Signature of applicant or applicant’s solicitor or other duly authorised agent
(See guidance note 4). If signing on behalf of the applicant please state in what
capacity.
Signature
…………………………………………………………………………………………………
Date
…………………………………………………………………………………………………
Capacity
…………………………………………………………………………………………………
Contact name (where not previously given) and postal address for
correspondence associated with this application (please read guidance note 5)
Post town
Post Code
Telephone number (if any)
If you would prefer us to correspond with you using an e-mail address your e-
mail address (optional)
Notes for Guidance
1. The ground(s) for review must be based on one of the licensing objectives.
2. Please list any additional information or details for example dates of problems
which are included in the grounds for review if available.
3. The application form must be signed.
4. An applicant’s agent (for example solicitor) may sign the form on their behalf
provided that they have actual authority to do so.
5. This is the address which we shall use to correspond with you about this
application.
click to sign
signature
click to edit
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