ࡱ>  ZbjbjVV <<"99999T% 5t !!!!qH }!dn4p4p4p4p4p4p4 79*p49!qq!!p499!!PQ5%%%!9!9!n4%!n4%%R"./! O%/Z4g5054/f9%9</99/!!%!!!!!p4p4%!!!5!!!!9!!!!!!!!! : Application for a provisional statement 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 the application should be made on the relevant form for that type of premises.  Part 1 Type of premises to which the application relatesRegional Casino  FORMCHECKBOX Large Casino  FORMCHECKBOX Small Casino  FORMCHECKBOX Bingo  FORMCHECKBOX Adult Gaming Centre  FORMCHECKBOX Family Entertainment Centre  FORMCHECKBOX Betting (Track)  FORMCHECKBOX Betting (Other)  FORMCHECKBOX  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 or proposed 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 or proposed 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 or proposed 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?  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FORMTEXT Yes/No [delete as appropriate] 18(b) If the answer to question 18(a) is yes, please provide full details:  FORMTEXT      19. 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  Checklist:Payment of the appropriate fee has been made/is enclosed  FORMCHECKBOX A plan of the premises or proposed 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  Signatures20. 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       21. 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 20 and 21.] [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 8  Contact Details22(a) Please give the name of a person who can be contacted about the application:  FORMTEXT      22(b) Please give one or more telephone numbers at which the person identified in question 22(a) can be contacted:  FORMTEXT      23. Postal address for correspondence associated with this application:  FORMTEXT      Postcode: FORMTEXT      24. 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