ࡱ> bda ?bjbj H{{((kkkkk44lp1t?0000000250uk0kk*1FFF kk0F0FF-lk0GF.*0@10p1!/J^6L^6Tk0^6kk04F00Fp1^6( 1: APPLICATION FORM FOR REGISTRATION OF NON-COMMERCIAL SOCIETY  If you are completing this form by hand, please write legibly in block capitals using ink. To: The Licensing Section, , Town Hall & Civic Offices, Westoe Road, South Shields, Tyne & Wear, NE33 2RL. Tel: 0191 4247695  [insert name and address of relevant local authority this is the local authority for the area in which the principal premises of the society are situated] SECTION A Details of society applying for registration 1. Name of society  FORMTEXT       2. Address (including postcode) of office or head office of society  FORMTEXT       3. Telephone number of society  FORMTEXT       4. Please state the purpose(s) for which the society is established and conducted  FORMTEXT       5. If the society is a registered charity, please give the society s unique charity registration number  FORMTEXT       6. Has the society held an operating licence under the Gambling Act 2005 in the period of five years ending with the date of this application? Yes  FORMCHECKBOX  No  FORMCHECKBOX  7. If the answer to question 6 is Yes, has the operating licence been revoked in the period of five years ending with the date of this application? Yes  FORMCHECKBOX  No  FORMCHECKBOX  8. If the answer to question 7 is Yes, please state the reasons for revocation and enclose a copy of the notice of revocation if one is available  FORMTEXT       9. Has the society applied for and been refused an operating licence in the period of five years ending with the date of this application? Yes  FORMCHECKBOX  No  FORMCHECKBOX   SECTION B  General information about person applying on behalf of society 10. Name  FORMTEXT       11. Capacity  FORMTEXT       12. Address (including postcode)  FORMTEXT       13. Daytime telephone number  FORMTEXT       SECTION C  Contact details for correspondence associated with this application 14. Please tick one box as appropriate to indicate address for correspondence in relation to this application:Address in section A  FORMCHECKBOX  Address in section B  FORMCHECKBOX Address below  FORMCHECKBOX  Address (including postcode)  FORMTEXT       Telephone number  FORMTEXT       Email address (if the applicant is happy for correspondence in relation to this application to be sent via e-mail)  FORMTEXT       SECTION D  Declaration 15. Please complete the following declaration>?+ . = > A B 4 ` b v x z ýwgTg%jh CJOJQJU^Jjh CJOJQJU^Jh 6CJ]aJh CJOJQJ^Jjh CJUaJh CJaJh 5CJ\h /5CJ\hSR5CJ\ hSRCJhSRhSR5CJ\hSRh 5CJ\h 5CJ\aJh 5CJOJQJ\^J h 5\h <=>? $$Ifa$fkd$$IflW&0644 la$If$If/ 0 ? @ A $If $Ifgd /fkd$$IflW&0644 laA B ||$If|kdU$$Ifl4_0& ` 0644 laf4 6 8 `  < > @ |||||||||||||$If|kd($$Ifl4!0&   0644 laf4z   * , . 8 : P R f h j t v N P d f h r t STbcdhiwλΨΕ΂o%jh CJOJQJU^J%jh CJOJQJU^J%jCh CJOJQJU^J%jh CJOJQJU^J%joh CJOJQJU^Jh CJOJQJ^Jjh CJOJQJU^J*jh CJOJQJU^JmHnHu& P x z | N v x z{@A$Ifwxy()*./=>?  :<XZ\dfнЪЗ܁ubO%jh CJOJQJU^J%jQh CJOJQJU^Jh /CJOJQJ^J*jh CJOJQJU^JmHnHu%jh CJOJQJU^J%jsh CJOJQJU^J%jh CJOJQJU^Jh CJOJQJ^Jjh CJOJQJU^J%jh CJOJQJU^J0FH\^`jl bdxz|r_%j{h CJOJQJU^J%jh CJOJQJU^J%jh CJOJQJU^J%j'h CJOJQJU^J*jh CJOJQJU^JmHnHu%jh CJOJQJU^Jh 5CJOJQJ\^Jh CJOJQJ^Jjh CJOJQJU^J%02Fnp$Ifdkd9$$Ifl&0644 la"$&bdkde$$Ifl&0644 la$If  $If $$Ifa$dkd$$Ifl&0644 la()  46JLNXZDFZ\^hjpr_%jh CJOJQJU^J%j7h CJOJQJU^J*jh CJOJQJU^JmHnHu%jh CJOJQJU^J%jch CJOJQJU^Jh 5CJOJQJ\^J%jh CJOJQJU^Jh CJOJQJ^Jjh CJOJQJU^J%4\^Dltnnnnnnnnnn$Ifkd$$IflFh =&06    44 la lnpr 6"6>6f6h6h7j777$Ifdkd $$Ifl&0644 la and checklist: I [Full Name]  FORMTEXT       a. make this application on behalf of the society referred to in Section A and have authority to act on behalf of that society. b. enclose payment of the registration fee of 40.  c. confirm that, to the best of my knowledge, the information contained in this application is true. I understand that it is an offence under section 342 of the Gambling Act 2005 to give information which is false or misleading in, or in relation to, this application. Signature Date  FORMTEXT       Capacity  FORMTEXT       Note to societies applying for registration: The application will be refused if in the period of five years ending with the date of the application: (a) an operating licence held by the society has been revoked under section 119(1) of the Gambling Act 2005, or (b) an application for an operating licence made by the society has been refused. The application may be refused if the local authority think that: (a) the society is not a non-commercial society, (b) a person who will or may be connected with the promotion of the lottery has been convicted of a relevant offence, or (c) information provided in or with the application is false or misleading.  6&6>6@6T6V6X6b6d67779::0:2:4:>:@:T:V:j:l:n:x:z:???ҩҩtҩҚph %jh CJOJQJU^J%jh CJOJQJU^Jh 5CJOJQJ\^J*jh CJOJQJU^JmHnHu%jh CJOJQJU^Jjh CJOJQJU^Jh 6CJOJQJ]^Jh CJOJQJ^JU77777999:tPJJJJJ$If#$d%d&d'dNOPQ%$d%d&d'dNOPQdkd$$Ifl&0644 la:::B:T:|:~::::;<0=2==> ???$If???dkd_$$Ifl0(#%0%644 la9 0P1h. A!n"n#n$n% Dp9 0P1h. A!n"n#n$n% Dp,1h. 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