Application for a provisional statement to be granted under the Licensing Act 2003

Premises
 

Premises name
Telephone number at premises
Non-domestic rateable value of premises*
Applicant details

Please state whether you are applying for a premises licence as:












*If you are applying as a person described in (a) or (b) please confirm:

  I am carrying on or proposing to carry on a business which involves the use of the premises for licensable activities;

*I am making the application pursuant to a


Individual applicant (fill in as applicable)
Title*
Surname*
First name*
Are you over 18?*
Country *
Address*
Post town*
Post code*
 

Telephone*
Email*
Second applicant (fill in as applicable)
Title
Surname
First name
Are you over 18?
Country
Address
Post town
Post code
 

Telephone
Email

If there are more than two applicants please contact Licensing Service on 02083562431.



OTHER APPLICANTS

Please provide the name and registered address of the applicant in full. Where appropriate please give any registered number.

Name*
Country *
Address*
Post town*
Post code*
 

Registered number (where applicable)
Telephone*
Email*
Description of applicant(for example, partnership,company,unincorprated association) Max characters: 60

Please select you correspondence address:



Alternative address

Please provide correspondence name and address in full

Name*
Country *
Address*
Post town*
Post code*
 

Telephone*
Email*