ࡱ>  `bjbjVV :<<$#  SSSSSggg8#gy2Dm x11111113_6*1Sq mmq q 1SSp32?%?%?%q VSS1?%q 1?%?%0h81ܲg"V0x1I20y206%"6 816S81@q q ?%q q q q q 11?%q q q y2q q q q 6q q q q q q q q q  : Declaration for a club premises certificate to be granted under the Licensing Act 2003 PLEASE READ THE FOLLOWING INSTRUCTIONS BEFORE COMPLETING DECLARATION 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. Club Premises details Name of club  FORMTEXT       Postal address of club, if any, or, if none, ordnance survey map reference or description  FORMTEXT      Post Town  FORMTEXT      Postcode  FORMTEXT      Telephone number (if any)  FORMTEXT      E-mail (optional)  FORMTEXT       CLUB DECLARATION AS TO QUALIFYING CLUB STATUS  FORMTEXT      (Insert name of club) club makes the following declarations Where the club to which this application relates is: a registered society within the meaning of the Industrial and Provident Societies Act 1965, a registered society within the meaning of the Friendly Societies Act 1974 or a registered friendly society within the meaning of the Friendly Societies Act, the club declares that the club satisfies: Please tick Yes Condition 1 in section 62(2) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant club rule number(s)  FORMTEXT       Condition 2 in section 62(3) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant club rule number(s)  FORMTEXT       Condition 4 in section 62(5) of the Licensing Act 2003  FORMCHECKBOX   FORMTEXT       Does the club wish to supply alcohol to members and guests?  FORMCHECKBOX  If yes the club declares that - The purchase of alcohol for the club and the supply of alcohol by the club is under the control of the members or of a committee appointed by the members  FORMCHECKBOX  Please give relevant club rule number(s), if any  FORMTEXT       Where the club to which this application relates is: an association organised for the social well-being and recreation of persons employed in or about coal mines, the club declares that the club satisfies: Please tick Yes Condition 1 in section 62(2) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant club rule number(s)  FORMTEXT       Condition 2 in section 62(3) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant club rule number(s)  FORMTEXT       Does the club wish to supply alcohol to members and guests?  FORMCHECKBOX  If yes the club declares that it satisfies - First condition in section 66(4) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant club rule number(s), if any  FORMTEXT       Second condition in section 66(5) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant club rule number(s), if any  FORMTEXT       Where the club to which this application relates does not fall into the categories in 1 or 2 above, the club declares that the club satisfies: Please tick Yes Condition 1 in section 62(2) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant club rule number(s)  FORMTEXT       Condition 2 in section 62(3) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant club rule number(s) 9:VWX * . 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hVCJOJQJU^JhL[*jhACJOJQJU^JmHnHu%jdhVCJOJQJU^J%jhVCJOJQJU^JjhVCJOJQJU^JhACJOJQJ^JhL[CJOJQJ^J(BDF^`"$Ifbkd$$Ifl=X X 044 lal"$02 z|$If$a$bkd- $$Ifl=X X 044 lal  VXtvx| xz*+UVnoz{бО܈ĄuqhAhA5CJOJQJ\^JhL[*jhACJOJQJU^JmHnHu%j hVCJOJQJU^J%j hVCJOJQJU^JhL[CJOJQJ^JhACJOJQJ^JjhVCJOJQJU^J%j hVCJOJQJU^J&  zVo{}}}w$If$ a$$a$h^h & Fbkd $$Ifl=X X 044 lal    *,.04ıܛЗĄqܛЗ^%j5hVCJOJQJU^J%jJhVCJOJQJU^J%j hVCJOJQJU^JhL[*jhACJOJQJU^JmHnHu%j hVCJOJQJU^JhACJOJQJ^JhL[CJOJQJ^JjhVCJOJQJU^J%jw hVCJOJQJU^J$.$If$a$bkd_ $$Ifl=X X 044 lal .02424>@h$If$a$bkd$$Ifl=X X 044 lal 04<@BVXZdfhjn  rvx؜r؜%j~hVCJOJQJU^J%jhVCJOJQJU^JhL[*jhACJOJQJU^JmHnHu%jhVCJOJQJU^J%jhVCJOJQJU^JjhVCJOJQJU^JhL[CJOJQJ^JhACJOJQJ^J,hjlntv$If$a$bkd$$Ifl=X X 044 lal~~~~~x$If$a$ & Fex^e` ^ bkd$$Ifl=X X 044 lal ^`|~|~ NNNNN$N&N(N*N.NNNNДlД%j@hVCJOJQJU^JU%jhVCJOJQJU^J*jhACJOJQJU^JmHnHu%jhVCJOJQJU^J%jihVCJOJQJU^JjhVCJOJQJU^JhACJOJQJ^JhL[CJOJQJ^JhL[hA* (N$If$a$bkdS$$Ifl=X X 044 lal  FORMTEXT       Condition 3 in section 62(4) of the Licensing Act 2003  FORMCHECKBOX  The club s arrangements for restricting the club s freedom of purchase of alcohol are: (a) contained in club rule number(s),  FORMTEXT       (b) or, as follows (please provide a short description)  FORMTEXT       The club s provisions by which money or property of the club or any gain arising from the carrying on of the club is or may be applied for charitable benevolent or political purposes are: (a) contained in club rule number(s),  FORMTEXT       or, as follows (please provide a short description)  FORMTEXT       The arrangements for giving members information about the finances of the club are: contained in club rule number(s),  FORMTEXT       or, as follows (please provide a short description)  FORMTEXT       Please describe details of the books of account and other records kept to ensure the accuracy of the information about finances given to members of the club or give the relevant rule number(s) FORMTEXT       Please tick Yes Condition 4 in section 62(5) of the Licensing Act 2003  FORMCHECKBOX  Condition 5 in section 62(6) of the Licensing Act 2003  FORMCHECKBOX  The club proposes to supply alcohol to members and guests  FORMCHECKBOX  and declares that the club satisfies: additional condition 1 in section 64(2) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant club rule number(s), if any  FORMTEXT       additional condition 2 in section 64(3) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant rule number(s), if any  FORMTEXT       additional condition 3 in section 64(4) of the Licensing Act 2003  FORMCHECKBOX  Please give relevant club rule number(s), if any  FORMTEXT       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 I FORMTEXT      ,make this declaration on behalf of the club and have authority to bind the club Signature & & & & & & & & & & & & & & & & & & & & & & & & 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