ࡱ > bjbjVV P < < 5! d A A A , A 6 t a c! ! P a5 c5 c5 c5 c5 c5 c5 7 : * c5 O" a a O" O" c5 P D6 " " " O" F a5 " O" a5 " " n ]- / 0m A "
e. M5 Z6 0 6 . : " : @ / : / < O" O" " O" O" O" O" O" c5 c5 " O" O" O" 6 O" O" O" O" : O" O" O" O" O" O" O" O" O" : 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 a s a c o m p a n y o r p a r t n e r s h i p ) , p l e a s e f i l l i n S e c t i o n B .
S e c t i o n A
I n d i v i d u a l a p p l i c a n t
1 . T i t l e : M r F O R M C H E C K B O X M r s F O R M C H E C K B O X M i s s F O R M C H E C K B O X M s F O R M C H E C K B O X D r F O R M C H E C K B O X O t h e r ( p l e a s e s p e c i f y ) F O R M T E X T 2 . S u r n a m e : F O R M T E X T O t h e r n a m e ( s ) : F O R M T E X T [ U s e t h e n a m e s g i v e n i n t h e a p p l i c a n t s o p e r a t i n g l i c e n c e o r , i f t h e a p p l i c a n t d o e s n o t h o l d a n o p e r a t i n g l i c e n c e , a s g i v e n i n a n y a p p l i c a t i o n f o r a n o p e r a t i n g l i c e n c e ] 3 . A p p l i c a n t s a d d r e s s ( F O R M T E X T h o m e o r b u s i n e s s [ d e l e t e a s a p p r o p r i a t e ] ) :
F O R M T E X T P o s t c o d e : F O R M T E X T 4 ( a ) T h e n u m b e r o f t h e a p p l i c a n t s o p e r a t i n g l i c e n c e ( a s s e t o u t i n t h e o p e r a t i n g l i c e n c e ) : F O R M T E X T 4 ( b ) I f t h e a p p l i c a n t d o e s n o t h o l d a n o p e r a t i n g l i c e n c e b u t i s i n t h e p r o c e s s o f a p p l y i n g f o r o n e , g i v e t h e d a t e o n w h i c h t h e a p p l i c a t i o n w a s m a d e : F O R M T E X T 5 . T i c k t h e b o x i f t h e a p p l i c a t i o n i s b e i n g m a d e b y m o r e t h a n o n e p e r s o n . F O R M C H E C K B O X
[ W h e r e t h e r e a r e f u rther 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
[ U s e t h e n a m e s g i v e n i n t h e a p p l i c a n t s o p e r a t i n g l i c e n c e o r , i f t h e a p p l i c a n t d o e s n o t h o l d a n o p e r a t i n g l i c e n c e , a s g i v e n i n a n y a p p l i c a t i o n f o r a n o p e r a t i n g l i c e n c e . ] 7 . T h e a p p l i c a n t s r e g i s t e r e d o r p r i n c i p a l a d d r e s s :
F O R M T E X T P o s t c o d e : F O R M T E X T 8 ( a ) T h e n u m b e r o f t h e a p p l i c a n t s o p e r a t i n g l i c e n c e ( a s g i v e n i n t h e o p e r a t i n g l i c e n c e ) :
F O R M T E X T 8 ( b ) I f t h e a p p l i c a n t d o e s n o t h o l d a n o p e r a t i n g l i c e n c e b u t i s i n t h e p r o c e s s o f a p p l y i n g f o r o n e , g i v e t h e d a t e o n w h i c h t h e a p p l i c a t i o n w a s m a d e : F O R M T E X T 9 . T i c k t h e b o x i f t h e a p p l i c a t i o n i s b e i n g m a d e b y m o r e t h a n o n e o r g a n i s a t i o n . F O R M C H E C K B O X
[ W h e r e t h e r e a r e f u r t h e r a p p l i c a n t s , t h e i n f o r m a t i o n r e q u i r e d i n q u e s t i o n s 6 t o 8 s h o u l d b e i n c l u d e d o n a d d i t i o n a l s h e e t s a t t a c h e d t o t h i s f o r m , a n d t h o s e s h e e t s s h o u l d b e c l e a r l y m a r k e d D e t a i l s o f f u r t h e r a p p l i c a n t s . ]
P a r t 2 P r e m i s e s D e t a i l s 1 0 . T r a d i n g n a m e u s e d a t l i c e n s e d p r e m i s e s : F O R M T E X T 1 1 . G i v e t h e a d d r e s s o f t h e p r e m i s e s o r , i f n one, 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 P o s t c o d e : F O R M T E X T 1 2 . T e l e p h o n e n u m b e r a t p r e m i s e s ( i f k n o w n ) : F O R M T E X T
1 3 . T y p e o f p r e m i s e s l i c e n c e t o b e v a r i e d : R e g i o n a l C a s i n o F O R M C H E C K B O X L a r g e C a s i n o F O R M C H E C K B O X S m a l l C a s i n o F O R M C H E C K B O X C o n v e r t ed 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
1 5 . I f y o u a r e m a k i n g t h i s a p p l i c a t i o n a l o n g s i d e a n a p p l i c a t i o n f o r t r a n s f e r o r r e i n s t a t e m e n t o f t h e p r e m i s e s l i c e n c e i n t o y o u r n a m e , p l e a s e g i v e t h e n a m e o f t h e c u r r e n t l i c e n c e h o l d e r a s i t a p p e a r s o n t h e p r e m i s e s l i c e n c e ( i f k n o w n ) : S u r n a m e : F O R M T E X T O t h e r n a m e ( s ) : F O R M T E X T
P a r t 3 D e t a i l s o f v a r i a t i o n s a p p l i e d f o r 1 6 ( a ) P l e a s e g i v e d e t a i l s o f a n y v a r i a t i o n w h i c h i s b e i n g a p p l i e d f o r . W h e r e t h e a p p l i c a t i o n i n c l u d e s a n a p p l i c a t i o n t o e x c l u d e o r v a r y a c o n d i t i o n o f t h e p r e m i s e s l i c e n c e , i d e n t i f y t h e r e l e v a n t c o n d i t i o n h e r e ( u n l e s s i t r e l a t e s t o h o u r s o f o p e r a t i o n w h i c h a r e d e a l t w i t h i n q u e s t i o n s 1 6 ( b ) a n d 1 6 ( c ) ) : F O R M T E X T 1 6 ( b ) D o y o u w a n t t h e l i c e n s i n g a u t h o r i t y t o e x c l u d e o r v a r y a c o n d i t i o n o f t h e l i c e n ce 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 C D E F G s t i j k l q r <
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l a p( ytn h h : m m F O R M T E X T h h : m m F O R M T E X T T u e F O R M T E X T F O R M T E X T F O R M T E X T W e d F O R M T E X T F O R M T E X T F O R M T E X T T h u r s F O R M T E X T F O R M T E X T F O R M T E X T F r i F O R M T E X T F O R M T E X T F O R M T E X T S a t F O R M T E X T F O R M T E X T F O R M T E X T S u n F O R M T E X T F O R M T E X T F O R M T E X T 1 7 . P l e a s e i n d i c a t e a n y p a r t i c u l a r d a t e o n w h i c h y o u w a n t t h e v a r i a t i o n t o t a k e e f f e c t i f a p p r o v e d : F O R M T E X T ( d d / m m / y y y y ) 1 8 . P l e a s e s e t o u t a n y o t h e r m a t t e r s w h i c h y o u c o n s i d e r t o b e r e l e v a n t t o y o u r a p p l i c a t i o n :
F O R M T E X T
P a r t 4 D e c l a r a t i o n s a n d C h e c k l i s t ( P l e a s e t i c k a s a p p r o p r i a t e ) I / W e c o n f i r m t h a t , t o t h e b e s t o f m y / o u r k n o w l e d g e , t h e i n f o r m a t i o n c o n t a i n e d i n t h i s a p p l i c a t i o n i s t r u e . I / W e u n d e r s t a n d t h a t i t i s a n o f f e n c e u n d e r s e c t i o n 3 4 2 o f t h e G a m b l i n g A c t 2 0 0 5 t o g i v e i n f o r m a t i o n w h i c h i s f a l s e o r m i s l e a d i n g i n , o r i n r e l a t i o n t o , t h i s a p p l i c a t i o n . F O R M C H E C K B O X I / W e c o n f i r m t h a t t h e a p p l i c a n t ( s ) h a v e t h e r i g h t t o o c c u p y t h e p r e m i s e s . F O R M C H E C K B O X C h e c k l i s t : P a y m e n t o f t h e a p p r o p r i a t e f e e h a s b e e n m a d e / i s e n c l o s e d F O R M C H E C K B O X A p l a n o f t h e p r e m i s e s i s e n c l o s e d F O R M C H E C K B O X T h e e x i s t i n g p r e m i s e s l i c e n c e i s e n c l o s e d F O R M C H E C K B O X T h e e x i s t i n g p r e m i s e s l i c e n c e i s n o t e n c l o s e d , b u t t h e a p p l i c a t i o n i s a c c o m p a n i e d b y A s t a t e m e n t e x p l a i n i n g w h y i t i s n o t r e a s o n a b l y p r a c t i c a b l e t o p r o d u c e t h e l i c e n c e a n d , F O R M C H E C K B O X A n a p p l i c a t i o n u n d e r t h e S e c t i o n 1 9 0 o f t h e G a m b l i n g A c t 2 0 0 5 f o r t h e i s s u e o f a c o p y o f t h e l i c e n c e F O R M C H E C K B O X I / w e u n d e r s t a n d t h a t i f t h e a b o v e r e q u i r e m e n t s a r e n o t c o m p l i e d w i t h t h e a p p l i c a t i o n m a y b e r e j e c t e d F O R M C H E C K B O X I / w e u n d e r s t a n d t h a t i t i s n o w n e c e s s a r y t o a d v e r t i s e t h e a p p l i c a t i o n a n d g i v e t h e a p p r o p r i a t e n o t i c e t o t h e r e s p o n s i b l e a u t h o r i t i e s F O R M C H E C K B O X
P a r t 5 S i g n a t u r e s 1 9 . S i g n a t u r e o f a p p l i c a n t o r a p p l i c a n t s s o l i c i t o r o r o t h e r d u l y a u t h o r i s e d a g e n t . I f s i g n i n g o n b e h a l f o f t h e a p p l i c a n t , p l e a s e s t a t e i n w h a t c a p a c i t y :
S i g n a t u r e :
P r i n t N a m e : F O R M T E X T D a t e : F O R M T E X T ( d d / m m / y y y y ) C a p a c i t y : F O R M T E X T
2 0 . F o r j o i n t a p p l i c a t i o n s , s i g n a t u r e o f 2 n d a p p l i c a n t , o r 2 n d a p p l i c a n t s s o l i c i t o r o r o t h e r a u t h o r i s e d a g e n t . I f s i g n i n g o n b e h a l f o f t h e a p p l i c a n t , p l e a s e s t a t e i n w h a t c a p a c i t y :
S i g n a t u r e :
P r i n t N a m e : F O R M T E X T D a t e : F O R M T E X T ( d d / m m / y y y y ) C a p a c i t y : F O R M T E X T
[ W h e r e t h e r e a r e m o r e t h a n t w o a p p l i c a n t s , p l e a s e u s e a n a d d i t i o n a l s h e e t c l e a r l y m a r k e d S i g n a t u r e ( s ) o f f u r t h e r a p p l i c a n t ( s ) . T h e s h e e t s h o u l d i n c l u d e a l l t h e i n f o r m a t i o n r e q u e s t e d i n p a r a g r a p h s 1 9 a n d 2 0 . ]
[ W h e r e t h e a p p l i c a t i o n i s t o b e s u b m i t t e d i n a n e l e c t r o n i c f o r m , t h e s i g n a t u r e s h o u l d b e g e n e r a t e d e l e c t r o n i c a l l y a n d s h o u l d b e a c o p y o f t h e p e r s o n s w r i t t e n s i g n a t u r e . ]
P a r t 6 C o n t a c t D e t a i l s 2 1 ( a ) P l e a s e g i v e t h e n a m e o f a p e r s o n w h o c a n b e c o n t a c t e d a b o u t t h e a p p l i c a t i o n :
F O R M T E X T 2 1 ( b ) P l e a s e g i v e o n e o r m o r e t e l e p h o n e n u m b e r s a t w h i c h t h e p e r s o n i d e n t i f i e d i n q u e s t i o n 2 1 ( a ) c a n b e c o n t a c t e d :
F O R M T E X T 2 2 . P o s t a l a d d r e s s f o r c o r r e s p o n d e n c e a s s o c i a t e d w i t h t h i s a p p l i c a t i o n :
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