Checklist
Temporary Authority
Sale and Supply of Alcohol Act 2012
The following must be included in your application or it will be returned
Please tick when completed:
Completed application form
Prescribed fee of $296.70
A copy of your lease agreement or sale and purchase agreement
Certificate of Incorporation (if applicable)
Covering letter including any additional information relevant to this application.
Copies of Managers’ Certificates
Completed Building Owner’s Approval (if applicant is not the owner; attached)
Notes:
The applicant must be the person or entity that will take any money from the sale of alcohol.
Additional information may be requested during the processing period.
The fee is non-refundable
Fees
The Temporary Authority fee of $296.70 includes GST and is non-refundable.
O
ffice Use Only
Notes:
Payment received:
/ /
Temporary Authority applications take up to 15 working days to process. Applications received outside the
timeframe might not be processed in time.
Application
Temporary Authority
Sale and Supply of Alcohol Act 2012
1 Licence Details
To: The Secretary
District Licensing Committee
(Please tick one)
Carterton
Masterton
South Wairarapa
a) Existing Licence type and number (choose one):
On-
Licence ____________________
Off-Licence ____________________
2 Applicant Details
3 Premises Details (not a conveyance)
Address
Trading name
4 Conveyance Details
Type (car, bus, railway carriage etc.)
Address or Home Base
Trading name
a) Full name(s) to be on authority (Exact company name as shown on certificate of incorporation, or your full legal name):
b) Postal address for service of documents:
c) Contact Details:
Name
NCS No.
Email
Website
Preferred means of formal contact
Telephone
Mobile
Mail Email
2
b) What right, title, estate or interest does the applicant have in any business conducted in the premises or conveyance?
c) Will the applicant carry on the sale and supply of alcohol personally?
d
) If
No - What is the full legal name and address of the person who will carry on the sale and supply of alcohol?
Yes No
Name
Address
6 Further Details
a) What right, title, estate or interest does the applicant have in the premises or conveyance?
e) W
hat are the reasons for this application (purchased business, etc.)?
Applications must be submitted to the local council where the premises or conveyance is located:
District Licensing Committee
Masterton District Council
PO Box 444
Masterton 5840
T 06 370 6300
E alcohol@mstn.govt.nz
www.mstn.govt.nz
District Licensing Committee
Carterton District Council
PO Box 9
Carterton 5743
T 06 379 4030
E health@cdc.govt.nz
www.cdc.govt.nz
District Licensing Committee
South Wairarapa District Council
PO Box 6
Martinborough 5741
T 06 306 9611
E health@swdc.govt.nz
www.swdc.govt.nz
5 Managers’ Details
NOTES:
1. The New Zealand Police are required by the Sale and Supply of Alcohol Act 2012 to make enquiries into the suitability of the applicant.
This will involve the Police informing the District Licensing Committee of any convictions or concerns involving the applicant. Should there
be any concerns, the applicant will also be informed.
2. This application, including personal information, will be available to the public and media as part of the District Licensing Committee’s
decision-making process.
3. The District Licensing Committee may require notice of this application to be given to any person or persons it may state.
f) What date do you intend to start trading from the premises?
Full Name Date of Birth Certificate Number Expiry Date
Da
ted this ________________ day of _____________ 20_______
Signature of Applicant ____________________________________
3
Temporary Authority
Building Owner’s Approval
______________________________________
Building Owner’s Signature
_
_____________________________________
Building Owner’s Name (print)
_
_____________________________________
Date
Premises name
Premises address
If the applicant is not the owner of the building, the owner must complete this form.
I HEREBY STATE THAT I have no objection to a Temporary Authority being granted
to allow the sale and supply of alcohol from the above premises.
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