Application for a review of 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.

1. Name of Applicant:
[Where the applicant is an individual please give your first name(s) as well as your surname]

or business	[check or tick appropriate box])

Postcode:

3(a) Are you making the application as a responsible authority?  Yes	No

3(b) If the answer to question 3(a) is yes, indicate the type of responsible authority:

4(a) If the answer to question 3(a) is no, please confirm by ticking or checking the box that you are applying as an interested party

4(b) If you have ticked or checked the box in answer to question 4(a), please indicate on what basis you qualify as an interested party:

[Where there are further applicants, the information required by questions 1 to 4(b) should be included on additional sheets attached to this form, and those sheets should be clearly marked

5.	Give the trading name used at the licensed premises to which the application for a review relates:

6.	Give the address of the premises or, if not known, give a description of the premises and its location.  Where the premises are a vessel, then (if known) give the place indicated in the premises

possible, any address should include a postcode:

Postcode:

7.	Type of premises:
Casino	Bingo Hall	Adult Gaming Centre
(arcade restricted to those who are 18 or over)
Betting (track)	Betting (other)	Family entertainment centre
(arcade which admits both over and under 18s)

8.	Premises licence (if known):

9.	Give the name of the person(s) or organisation(s) in whose name the licence is held.

[Where an individual is the licence holder please give their first name(s) as well as their surname.]

10(a) Please give details of the grounds on which a review is being sought.

10(b) Indicate any specific actions you consider the licensing authority should take following the review, including the reasons why you consider those actions are 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.
I/We understand that it is now necessary to give notice to the licence holder and the responsible authorities in relation to the premises

of the applicant, please state in what capacity:

Signature:

Print Name:
Date:	(dd/mm/yyyy)
Capacity:

[Where there is more than one applicant, please use an additional sheet clearly marked

the information requested in paragraph 12.]

[Where the application is to be submitted in an electronic form, the signature should be generated

13(a) Please give the name of a person who can be contacted about the application:

13(b) Please give one or more telephone numbers at which the person identified in question 13(a) can be contacted:

Postcode:

Personal Data
We have recently updated our Privacy Notice about how we use personal data provided to the Council. Further information can be found at:                 
 http://www.kirklees.gov.uk/beta/information-and-data/pdf/privacy-notice-licensing-gambling-act.pdf

15. If you are happy for correspondence in relation to the application to be sent via e-mail, please give the e-mail address to which you would like correspondence to be sent: