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.

If 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	Mrs	Miss	Ms	Dr	Other (please specify)	

2. Surname:					
Other name(s):	

operating licence, as given in any application for an operating licence]

[delete as appropriate]):

Postcode:

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:

5.	Tick the box if the application is being made by more than one person.
[Where there are further applicants, the information required in questions 1 to 4 should be included

Section B
Application on behalf of an organisation

6.	Name of applicant business or organisation:

operating licence, as given in any application for an operating licence.]

Postcode:

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:

9.	Tick the box if the application is being made by more than one organisation.
[Where there are further applicants, the information required in questions 6 to 8 should be included

10.	Trading name used at licensed premises:

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

should include an address with a postcode:

Postcode:

12.	Telephone number at premises (if known):

13.	Type of premises licence to be varied:
Regional Casino	Large Casino	Small Casino	
Converted Casino	Bingo	Adult Gaming Centre	
Betting (track)	Betting (other)	Family Entertainment Centre	

14.	Premises licence number (if known):

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:	Other name(s):

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)):

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?
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.

Start	Finish	Details of any seasonal variation
Mon	hh:mm	hh:mm
Tue Wed Thurs Fri Sat Sun

17.	Please indicate any particular date on which you want the variation to take effect if approved: (dd/mm/yyyy)

18.	Please set out any other matters which you consider to be relevant to your application:

(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.
I/ We confirm that the applicant(s) have the right to occupy the premises. Checklist:
Payment of the appropriate fee has been made/is enclosed A plan of the premises is enclosed
The existing premises licence is enclosed
The existing premises licence is not enclosed, but the application is

A statement explaining why it is not reasonably practicable to produce the licence and,
An application under the Section 190 of the Gambling Act 2005 for the issue of a copy of the licence
I/we understand that if the above requirements are not complied with the application may be rejected
I/ we understand that it is now necessary to advertise the application and give the appropriate notice to the responsible authorities

of the applicant, please state in what capacity: Signature:

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

agent. If signing on behalf of the applicant, please state in what capacity: Signature:

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

[Where there are more than two applicants, please use an additional sheet clearly marked

paragraphs 19 and 20.]

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

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

21(b) Please give one or more telephone numbers at which the person identified in question 21(a) can be contacted:

22.	Postal address for correspondence associated with this application:

Postcode:
23.	

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

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