[Insert name and address of relevant licensing authority and its reference number (optional).
]
Application for a premises licence to be granted
under the Licensing Act 2003
PLEASE READ THE !LL!"#$% #$STR&'T#!$S #RST
Before completing this form please read the guidance notes at the end of the form. If you are completing
this form by hand please write legibly in block capitals. In all cases ensure that your answers are inside the
boxes and written in black ink. Use additional sheets if necessary.
You may wish to keep a copy of the completed form for your records.
#("e
(Insert name(s) of applicant)
appl) for a premises licence under section *+ of the Licensing Act 2003 for the premises described in
Part * belo, -the premises. and #(,e are ma/ing this application to )ou as the rele0ant licensing
authorit) in accordance ,ith section *2 of the Licensing Act 2003
Part * 1 Premises Details
Postal address of premises or, if none, ordnance survey map reference or description
Post to,n Postcode
elephone number at premises !if any"
#on$domestic rateable value of premises 2
Part % $ &pplicant 'etails
Please state whether you are applying for a premises licence as
Please tick as appropriate
a" an individual or individuals ( please complete section !&"
b" a person other than an individual (
i. as a limited company please complete section !B"
ii. as a partnership please complete section !B"
iii. as an unincorporated association or please complete section !B"
iv. other !for example a statutory corporation" please complete section !B"
c" a recognised club please complete section !B"
d" a charity please complete section !B"
e" the proprietor of an educational establishment please complete section !B"
f" a health service body please complete section !B"
g"
ga"
a person who is registered under Part % of the )are
*tandards &ct %+++ !c,-" in respect of an independent
hospital in .ales
a person who is registered under )hapter % of Part ,
of the /ealth and *ocial )are &ct %++0 !within the
meaning of that Part" in an independent hospital in
1ngland
please complete section !B"
please complete section !B"
h" the chief officer of police of a police force in 1ngland
and .ales
please complete section !B"
( If you are applying as a person described in !a" or !b" please confirm2
Please tick yes
I am carrying on or proposing to carry on a business which involves the use of the premises for
licensable activities3 or
I am making the application pursuant to a
statutory function or
a function discharged by virtue of /er 4a5esty6s prerogative
-A. #$D#3#D&AL APPL#'A$TS !fill in as applicable"
4r
4rs 4iss 4s
7ther itle !for
example, 8ev"
Surname
irst names
I am ,0 years old or over Please tick yes
)urrent postal address if
different from premises
address
Post town Postcode
Da)time contact telephone number
E4mail address
-optional.
SE'!$D #$D#3#D&AL APPL#'A$T !if applicable"
4r
4rs 4iss 4s
7ther itle !for
example, 8ev"
Surname
irst names
I am ,0 years old or over Please tick yes
)urrent postal address if
different from premises
address
Post town Postcode
Da)time contact telephone number
E4mail address
-optional.
-5. !THER APPL#'A$TS
Please pro0ide name and registered address of applicant in full6 "here appropriate please gi0e an)
registered number6 #n the case of a partnership or other 7oint 0enture -other than a bod) corporate.8
please gi0e the name and address of each part) concerned6
#ame
&ddress
8egistered number !where applicable"
'escription of applicant !for example, partnership, company, unincorporated association etc."
elephone number !if any"
1$mail address !optional"
Part 3 !perating Schedule
.hen do you want the premises licence to start9
'' 44 YYYY
If you wish the licence to be valid only for a limited period, when do you
want it to end9
'' 44 YYYY
Please give a general description of the premises !please read guidance note ,"
If :,+++ or more people are expected to attend the premises at any one time,
please state the number expected to attend.
.hat licensable activities do you intend to carry on from the premises9
!Please see sections , and ,- of the ;icensing &ct %++< and *chedules , and % to the ;icensing &ct %++<"
Provision of regulated entertainment
Please tick any that
apply
a" plays !if ticking yes, fill in box &"
b" films !if ticking yes, fill in box B"
c" indoor sporting events !if ticking yes, fill in box )"
d" boxing or wrestling entertainment !if ticking yes, fill in box '"
e" live music !if ticking yes, fill in box 1"
f" recorded music !if ticking yes, fill in box ="
g" performances of dance !if ticking yes, fill in box >"
h"
anything of a similar description to that falling within !e", !f" or !g"
!if ticking yes, fill in box /"
Pro0ision of late night refreshment !if ticking yes, fill in box I"
Suppl) of alcohol !if ticking yes, fill in box ?"
#n all cases complete bo9es :8 L and ;
A
Pla)s
*tandard days and timings
!please read guidance note
@"
"ill the performance of a pla) ta/e place indoors
or outdoors or both 1 please tic/ !please read
guidance note %"
Indoors
7utdoors
'ay *tart =inish Both
4on Please gi0e further details here !please read guidance note <"
ue
.ed State an) seasonal 0ariations for performing pla)s !please read guidance
note -"
hur
=ri $on standard timings6 "here )ou intend to use the premises for the
performance of pla)s at different times to those listed in the column on
the left8 please list !please read guidance note :"
*at
*un
5
ilms
*tandard days and timings
!please read guidance note
@"
"ill the e9hibition of films ta/e place indoors or
outdoors or both 1 please tic/ !please read guidance
note %"
Indoors
7utdoors
'ay *tart =inish Both
4on Please gi0e further details here !please read guidance note <"
ue
.ed State an) seasonal 0ariations for the e9hibition of films !please read
guidance note -"
hur
=ri $on standard timings6 "here )ou intend to use the premises for the
e9hibition of films at different times to those listed in the column on the
left8 please list !please read guidance note :"
*at
*un
)
#ndoor sporting e0ents
*tandard days and timings
!please read guidance note
@"
Please gi0e further details !please read guidance note <"
'ay *tart =inish
4on
ue State an) seasonal 0ariations for indoor sporting e0ents !please read
guidance note -"
.ed
hur $on standard timings6 "here )ou intend to use the premises for indoor
sporting e0ents at different times to those listed in the column on the
left8 please list !please read guidance note :"
=ri
*at
*un
D
5o9ing or ,restling
entertainments
*tandard days and timings
!please read guidance note
@"
"ill the bo9ing or ,restling entertainment ta/e
place indoors or outdoors or both 1 please tic/
!please read guidance note %"
Indoors
7utdoors
'ay *tart =inish Both
4on Please gi0e further details here !please read guidance note <"
ue
.ed State an) seasonal 0ariations for bo9ing or ,restling entertainment
!please read guidance note -"
hur
=ri $on standard timings6 "here )ou intend to use the premises for bo9ing
or ,restling entertainment at different times to those listed in the
column on the left8 please list !please read guidance note :"
*at
*un
E
Li0e music
*tandard days and timings
!please read guidance note
@"
"ill the performance of li0e music ta/e place
indoors or outdoors or both 1 please tic/ !please
read guidance note %"
Indoors
7utdoors
'ay *tart =inish Both
4on Please gi0e further details here !please read guidance note <"
ue
.ed State an) seasonal 0ariations for the performance of li0e music !please
read guidance note -"
hur
=ri $on standard timings6 "here )ou intend to use the premises for the
performance of li0e music at different times to those listed in the column
on the left8 please list !please read guidance note :"
*at
*un
Recorded music
*tandard days and timings
!please read guidance note
@"
"ill the pla)ing of recorded music ta/e place
indoors or outdoors or both 1 please tic/ !please
read guidance note %"
Indoors
7utdoors
'ay *tart =inish Both
4on Please gi0e further details here !please read guidance note <"
ue
.ed State an) seasonal 0ariations for the pla)ing of recorded music !please
read guidance note -"
hur
=ri $on standard timings6 "here )ou intend to use the premises for the
pla)ing of recorded music at different times to those listed in the column
on the left8 please list !please read guidance note :"
*at
*un
%
Performances of dance
*tandard days and timings
!please read guidance note
@"
"ill the performance of dance ta/e place indoors
or outdoors or both 1 please tic/ !please read
guidance note %"
Indoors
7utdoors
'ay *tart =inish Both
4on Please gi0e further details here !please read guidance note <"
ue
.ed State an) seasonal 0ariations for the performance of dance !please read
guidance note -"
hur
=ri $on standard timings6 "here )ou intend to use the premises for the
performance of dance at different times to those listed in the column on
the left8 please list !please read guidance note :"
*at
*un
H
An)thing of a similar
description to that falling
,ithin -e.8 -f. or -g.
*tandard days and timings
!please read guidance note
@"
Please give a description of the type of entertainment you will be providing
'ay *tart =inish "ill this entertainment ta/e place indoors or
outdoors or both 1 please tic/ !please read guidance
note %"
Indoors
4on 7utdoors
Both
ue Please gi0e further details here !please read guidance note <"
.ed
hur
State an) seasonal 0ariations for entertainment of a similar description
to that falling ,ithin -e.8 -f. or -g. !please read guidance note -"
=ri
*at
$on standard timings6 "here )ou intend to use the premises for the
entertainment of a similar description to that falling ,ithin -e.8 -f. or -g.
at different times to those listed in the column on the left8 please list
!please read guidance note :"
*un
#
Late night refreshment
*tandard days and timings
!please read guidance note
@"
"ill the pro0ision of late night refreshment ta/e
place indoors or outdoors or both 1 please tic/
!please read guidance note %"
Indoors
7utdoors
'ay *tart =inish Both
4on Please gi0e further details here !please read guidance note <"
ue
.ed State an) seasonal 0ariations for the pro0ision of late night refreshment
!please read guidance note -"
hur
=ri $on standard timings6 "here )ou intend to use the premises for the
pro0ision of late night refreshment at different times8 to those listed in
the column on the left8 please list !please read guidance note :"
*at
*un
<
Suppl) of alcohol
*tandard days and timings
!please read guidance note
@"
"ill the suppl) of alcohol be for consumption 1
please tic/ !please read guidance note A"
7n the
premises
7ff the
premises
'ay *tart =inish Both
4on State an) seasonal 0ariations for the suppl) of alcohol !please read
guidance note -"
ue
.ed
hur $on standard timings6 "here )ou intend to use the premises for the
suppl) of alcohol at different times to those listed in the column on the
left8 please list !please read guidance note :"
=ri
*at
*un
State the name and details of the indi0idual ,hom )ou ,ish to specif) on the licence as designated
premises super0isor=
#ame
&ddress
Postcode
Personal licence number !if known"
Issuing licensing authority !if known"
B
Please highlight an) adult entertainment or ser0ices8 acti0ities8 other entertainment or matters
ancillar) to the use of the premises that ma) gi0e rise to concern in respect of children !please read
guidance note 0".
;
Hours premises are open
to the public
*tandard days and timings
!please read guidance note
@"
State an) seasonal 0ariations !please read guidance note -"
'ay *tart =inish
4on
ue
.ed
$on standard timings6 "here )ou intend the premises to be open to the
public at different times from those listed in the column on the left8
please list !please read guidance note :"
hur
=ri
*at
*un
; 'escribe the steps you intend to take to promote the four licensing ob5ectives2
a. %eneral 1 all four licensing ob7ecti0es -b8 c8 d and e. !please read guidance note C"
b. The pre0ention of crime and disorder
c. Public safet)
d" he prevention of public nuisance
e" he protection of children from harm
'hec/list=
Please tic/ to indicate agreement
I have made or enclosed payment of the fee.
I have enclosed the plan of the premises.
I have sent copies of this application and the plan to responsible authorities and others where
applicable.
I have enclosed the consent form completed by the individual I wish to be designated premises
supervisor, if applicable.
I understand that I must now advertise my application.
I understand that if I do not comply with the above reDuirements my application will be
re5ected.
#T #S A$ !E$'E8 L#A5LE !$ S&;;AR> '!$3#'T#!$ T! A #$E $!T E?'EED#$%
LE3EL @ !$ THE STA$DARD S'ALE8 &$DER SE'T#!$ *@A ! THE L#'E$S#$% A'T 20038
T! ;A:E A ALSE STATE;E$T #$ !R #$ '!$$E'T#!$ "#TH TH#S APPL#'AT#!$6
Part B 1 Signatures !please read guidance note ,+"
Signature of applicant or applicantCs solicitor or other dul) authorised agent !see guidance note ,,".
#f signing on behalf of the applicant8 please state in ,hat capacit)6
*ignature
'ate
)apacity
or 7oint applications8 signature of 2
nd
applicant or 2
nd
applicantCs solicitor or other authorised agent
!please read guidance note ,%". #f signing on behalf of the applicant8 please state in ,hat capacit)6
*ignature
'ate
)apacity
)ontact name !where not previously given" and postal address for correspondence associated with this
application !please read guidance note ,<"
Post town Postcode
elephone number !if any"
If you would prefer us to correspond with you by e$mail, your e$mail address !optional"
$otes for %uidance
,. 'escribe the premises, for example the type of premises, its general situation and layout and any
other information which could be relevant to the licensing ob5ectives. .here your application
includes off$supplies of alcohol and you intend to provide a place for consumption of these off$
supplies, you must include a description of where the place will be and its proximity to the
premises.
%. .here taking place in a building or other structure please tick as appropriate !indoors may include
a tent".
<. =or example the type of activity to be authorised, if not already stated, and give relevant further
details, for example !but not exclusively" whether or not music will be amplified or unamplified.
-. =or example !but not exclusively", where the activity will occur on additional days during the
summer months.
:. =or example !but not exclusively", where you wish the activity to go on longer on a particular day
e.g. )hristmas 1ve.
@. Please give timings in %- hour clock !e.g. ,@2++" and only give details for the days of the week
when you intend the premises to be used for the activity.
A. If you wish people to be able to consume alcohol on the premises, please tick Eon the premises6. If
you wish people to be able to purchase alcohol to consume away from the premises, please tick
Eoff the premises6. If you wish people to be able to do both, please tick Eboth6.
0. Please give information about anything intended to occur at the premises or ancillary to the use of
the premises which may give rise to concern in respect of children, regardless of whether you
intend children to have access to the premises, for example !but not exclusively" nudity or semi$
nudity, films for restricted age groups or the presence of gaming machines.
C. Please list here steps you will take to promote all four licensing ob5ectives together.
,+. he application form must be signed.
,,. &n applicant6s agent !for example solicitor" may sign the form on their behalf provided that they
have actual authority to do so.
,%. .here there is more than one applicant, each of the applicant or their respective agent must sign
the application form.
,<. his is the address which we shall use to correspond with you about this application.
