ࡱ>  bjbjVV [<<5!d/dU5tw ,4.4.4.4.4.4.46k9*.4.445,4,41D3z82&4%50U5299L393 .4.4U59 : Application to vary a premises licence under the Gambling Act 2005 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.  Part 1 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 2  Premises Details10. Trading name used at licensed premises:  FORMTEXT      11. Give the address of the premises or, if none, give a description of the premises and its location. Where the premises are a vessel, give the place indicated in the premises licence as the place in the licensing authoritys area where the vessel is wholly or partly situated. Where possible this should include an address with a postcode:  FORMTEXT      Postcode:  FORMTEXT      12. Telephone number at premises (if known):  FORMTEXT       13. Type of premises licence to be varied:Regional Casino  FORMCHECKBOX Large Casino  FORMCHECKBOX Small Casino  FORMCHECKBOX Converted Casino  FORMCHECKBOX Bingo  FORMCHECKBOX Adult Gaming Centre  FORMCHECKBOX Betting (track)  FORMCHECKBOX Betting (other)  FORMCHECKBOX Family Entertainment Centre  FORMCHECKBOX  14. Premises licence number (if known):  FORMTEXT       15. If you are making this application alongside an application for transfer or reinstatement of the premises licence into your name, please give the name of the current licence holder as it appears on the premises licence (if known):Surname:  FORMTEXT      Other name(s):  FORMTEXT        Part 3  Details of variations applied for 16(a) Please give details of any variation which is being applied for. Where the application includes an application to exclude or vary a condition of the premises licence, identify the relevant condition here (unless it relates to hours of operation which are dealt with in questions 16(b) and 16(c)):  FORMTEXT      16(b) Do you want the licensing authority to exclude or vary a condition of the licence so that the premises may be used for longer periods than would otherwise be the case?  FORMTEXT Yes/No [delete as appropriate]16(c) If the answer to question 16(b) 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 Fsl t    * , H J L T V r t v ~   , . 0 : < \ ^ r t v jhoUjkhoUjhoUmHnHujhoUj{hoUjhoUjhoUjhoUjhoUjhoU ho5\ho5DEFsti j k l dkd$$Ifl&0644 la$If $$Ifa$ r t $Iftkd$$Ifl&   0644 lap  /dkdc$$Ifl&0644 la$Ifdkd'$$Ifl&0644 la > $Ifdkd$$Ifl&0644 la $IfykdS$$Ifl|0&  0644 la $&(HJP~. ho5\ju hoUj hoUj hoUj hoUjhoUmHnHujhoUhomHnHujhoUjhoUho6CJ]aJho ho6]3 /dkd$$Ifl&0644 la$Ifdkd$$Ifl&0644 la-dkd $$Ifl&0644 la$Iffkd $$Ifl&0644 la "+fkd $$Ifl&0644 la$Iffkd $$Iflp&0644 labikd $$Ifl4Q&0644 laf4$If./9:  `   "$.0BDXZ\fh *,.0$|~,-jfhoU ho5\jhoUjhoUjhoUjuhoUjyhoU ho6]jhoUmHnHujw hoUhojhoU6bd(fkd$$Ifl&0644 la$Ifikd $$Ifl4c&0644 laf42468/dkdc$$Ifl&0644 ladkd$$Ifl&0644 la$Ifjl0-fkd?$$Iflp&0644 ladkdQ$$Ifl&0644 la$If0"dkd;$$Ifl&0644 la$If"$fkd$$Iflp&0644 la$Ifvkd$$Ifl&   0644 lap ,Lfkd$$Ifl &0644 la$If-78  $&:<>HJPRnpr    " # 1 2 3 H I W X Y k l jHhoUjhoUj`hoUj.hoUjhoUjFhoUjhoUjVhoUjhoUmHnHujhoUjdhoUho3LNPR+fkdH$$IflC&0644 la$Iffkd$$IflC&0644 la.0t-dkd$$Ifl&0644 lafkd:$$IflC&0644 la$Ift 4 Z nkd$$IflF &F06    44 la$IfZ [ } tnnnn$Ifkd$$IflF &F06    44 lal z { | !!" 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Please indicate any particular date on which you want the variation to take effect if approved:  FORMTEXT       (dd/mm/yyyy)18. Please set out any other matters which you consider to be relevant to your application:  FORMTEXT       Part 4  Declarations and Checklist (Please tick as appropriate)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 The existing premises licence is enclosed FORMCHECKBOX The existing premises licence is not enclosed, but the application is accompanied by  A statement explaining why it is not reasonably practicable to produce the licence and, FORMCHECKBOX An application under the Section 190 of the Gambling Act 2005 for the issue of a copy of the licence 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 5  Signatures19. 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       20. 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) . The sheet should include all the information requested in paragraphs 19 and 20.] [Where the application is to be submitted in an electronic form, the signature should be generated electronically and should be a copy of the person s written signature.] Part 6  Contact Details21(a) Please give the name of a person who can be contacted about the application:  FORMTEXT      21(b) Please give one or more telephone numbers at which the person identified in question 21(a) can be contacted:  FORMTEXT      22. Postal address for correspondence associated with this application:  FORMTEXT      Postcode: FORMTEXT      23. 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