ࡱ>  bjbjVV  <<H%99999T%9t-\u!i"|8888888p;>*89"""899P9&&&"998&"8&&n1o3s&j2 89092<>&<>@o3o3<>934""&"""""88&"""9""""<>""""""""" : Application for a premises licence under the Gambling Act 2005 (standard form) PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST If you are completing this form by hand, please write legibly in block capitals using ink. Use additional sheets if necessary (marked with the number of the relevant question). You may wish to keep a copy of the completed form for your records. Where the application is In respect of a vessel, or To convert an authorisation granted under the Betting, Gaming and Lotteries Act 1963 or the Gaming Act 1968, the application should be made on the relevant form for that type of premises or application. Part 1 Type of premises licence applied forRegional Casino  FORMCHECKBOX Large Casino  FORMCHECKBOX Small Casino  FORMCHECKBOX Bingo  FORMCHECKBOX Adult Gaming Centre  FORMCHECKBOX Family Entertainment Centre  FORMCHECKBOX Betting (Track)  FORMCHECKBOX Betting (Other)  FORMCHECKBOX  Do you hold a provisional statement in respect of the premises? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If the answer is  yes , please give the unique reference number for the provisional statement (as set out at the top of the first page of the statement):  FORMTEXT        Part 2  Applicant DetailsIf you are an individual, please fill in Section A. If the application is being made on behalf of an organisation (such as a company or partnership), please fill in Section B. Section A Individual applicant 1. Title: Mr  FORMCHECKBOX  Mrs  FORMCHECKBOX  Miss  FORMCHECKBOX  Ms  FORMCHECKBOX  Dr  FORMCHECKBOX  Other (please specify)  FORMTEXT      2. Surname:  FORMTEXT      Other name(s):  FORMTEXT      [Use the names given in the applicant s operating licence or, if the applicant does not hold an operating licence, as given in any application for an operating licence]3. Applicant s address ( FORMTEXT home or business  [delete as appropriate]):  FORMTEXT      Postcode:  FORMTEXT      4(a) The number of the applicant s operating licence (as set out in the operating licence):  FORMTEXT       4(b) If the applicant does not hold an operating licence but is in the process of applying for one, give the date on which the application was made:  FORMTEXT       5. Tick the box if the application is being made by more than one person.  FORMCHECKBOX  [Where there are further applicants, the information required in questions 1 to 4 should be included on additional sheets attached to this form, and those sheets should be clearly marked Details of further applicants.] Section B Application on behalf of an organisation 6. Name of applicant business or organisation:  FORMTEXT       [Use the names given in the applicant s operating licence or, if the applicant does not hold an operating licence, as given in any application for an operating licence.]7. The applicant s registered or principal address:  FORMTEXT      Postcode:  FORMTEXT      8(a) The number of the applicant s operating licence (as given in the operating licence):  FORMTEXT      8(b) If the applicant does not hold an operating licence but is in the process of applying for one, give the date on which the application was made:  FORMTEXT       9. Tick the box if the application is being made by more than one organisation.  FORMCHECKBOX  [Where there are further applicants, the information required in questions 6 to 8 should be included on additional sheets attached to this form, and those sheets should be clearly marked  Details of further applicants .] Part 3  Premises Details10. Proposed trading name to be used at the premises (if known):  FORMTEXT       11. Address of the premises (or, if none, give a description of the premises and their location):  FORMTEXT      Postcode:  FORMTEXT      12. Telephone number at premises (if known):  FORMTEXT       13. If the premises are in only a part of a building, please describe the nature of the building (for example, a shopping centre or office block). The description should include the number of floors within the building and the floor(s) on which the premises are located.  FORMTEXT      14(a) Are the premises situated in more than one licensing authority area?  FORMTEXT Yes/No [delete as appropriate]14(b). If the answer to question 14(a) is yes, please give the names of all the licensing authorities within whose area the premises are partly located, other than the licensing authority to which this application is made:  FORMTEXT       Part 4  Times of operation15(a). Do you want the licensing authority to exclude a default condition so that the premises may be used for longer periods than would otherwise be the case?  FORMTEXT Yes/No [delete as appropriate] [Where the relevant kind of premises licence is not subject to any default conditions, the answer to this question will be no.] 15(b). If the answer to question 15(a) is yes, please complete the table below to indicate the times when you want the premises to be available for use under the premises licence. StartFinishDetails of any seasonal variationMon FORMTEXT       hh:mm FORMTEXT       hh:mm FORMTEXT      Tue FORMTEXT       FORMTEXT       FORMTEXT      Wed FORMTEXT        FORMTEXT       FORMTEXT      Thurs FORMTEXT       FORMTEXT       FORMTEXT      Fri FORMTEXT       FORMTEXT       FORMTEXT      Sat FORMTEXT       FORMTEXT       FORMTEXT      Sun FORMTEXT       FORMTEXT       FORMTEXT       16. 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Proposed commencement date for licence (leave blank if you want the licence to commence as soon as it is issued):  FORMTEXT       (dd/mm/yyyy) 18(a). Does the application relate to premises which are part of a track or other sporting venue which already has a premises licence?  FORMTEXT Yes/No [delete as appropriate]18(b). If the answer to question 18(a) is yes, please confirm by ticking the box that an application to vary the main track premises licence has been submitted with this application.  FORMCHECKBOX  19(a). Do you hold any other premises licences that have been issued by this licensing authority?  FORMTEXT Yes/ No [delete as appropriate]19(b). If the answer to question 19(a) is yes, please provide full details:  FORMTEXT      20. Please set out any other matters which you consider to be relevant to your application:  FORMTEXT       Part 6  Declarations and Checklist (Please tick)I/ We confirm that, to the best of my/ our knowledge, the information contained in this application is true. I/ We 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. FORMCHECKBOX I/ We confirm that the applicant(s) have the right to occupy the premises.  FORMCHECKBOX Checklist:Payment of the appropriate fee has been made/is enclosed  FORMCHECKBOX A plan of the premises is enclosed  FORMCHECKBOX I/ we understand that if the above requirements are not complied with the application may be rejected FORMCHECKBOX I/ we understand that it is now necessary to advertise the application and give the appropriate notice to the responsible authorities  FORMCHECKBOX  Part 7  Signatures21. Signature of applicant or applicant s solicitor or other duly authorised agent. If signing on behalf of the applicant, please state in what capacity: Signature: Print Name: FORMTEXT      Date: FORMTEXT       (dd/mm/yyyy)Capacity: FORMTEXT       22. For joint applications, signature of 2nd applicant, or 2nd applicant s solicitor or other authorised agent. If signing on behalf of the applicant, please state in what capacity: Signature: Print Name: FORMTEXT      Date: FORMTEXT       (dd/mm/yyyy)Capacity: FORMTEXT       [Where there are more than two applicants, please use an additional sheet clearly marked  Signature(s) of further applicant(s) . 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