APPLICATION FORM FOR CLUB GAMING PERMIT OR CLUB MACHINE PERMIT

(FOR USE BY APPLICANTS - MEMBERS’ CLUBS, COMMERCIAL CLUBS AND MINERS’               WELFARE INSTITUTES)	
If you are completing this form by hand, please write legibly in block capitals using ink.	
To:	Official use only - licensing authority logo or symbol	

[insert name and address of relevant licensing authority – this is the authority in whose area the premises relating to this application are wholly or partly situated]		
SECTION A – Type of Application
1. Please indicate type of application by ticking one of the boxes below:

Application for a club gaming permit Application for a club machine permit Application to renew a club gaming permit
Application to renew a club machine permit	

SECTION B – Existing registration under Gaming Act 1968
[To be completed if the applicant wishes to apply as an existing Part 2 or Part 3 operator. Do not complete if applying to renew a permit]

Part I
1.	Did the applicant have a Part 2 or Part 3 Registration under the Gaming Act 1968 that had effect on 31st August 2007? Yes	No

Part II – Complete if the answer to question 1 is ‘Yes’:
2.	Please indicate the date on which the registration was due to expire (i.e. the date it was fixed to expire when the registration was granted or last renewed)

3.	Is the date given in answer to question 2 a date after 31st August 2007? Yes	No

4.	If the answer to question 3 is ‘No’, was the applicant’s registration renewed on or after 1st September 2007? Yes	No

Please give date of renewal	

Part III – Complete if the answer to question 1 is ‘NO’:
5.	Was the applicant first registered under Part 2 or Part 3 of the Gaming Act 1968 on or after 1st September 2007? Yes	No

Please give date of first registration

Part IV
6.	If the answer to either question 1 or 5 is ‘Yes’, please indicate which type of registration: Part 2 Registration	Part 3 Registration

7.	Does this application relate to the same (or substantially the same) premises as those to which the registration relates? Yes	No

8.	Is this application made before the ‘relevant date’? Yes	No
[The ‘relevant date’ is the date on which the registration is due to expire, except where the applicant is registered for the first time on or after 1st September 2007, or the registration is renewed on or after that date. In those circumstances, the ‘relevant date’ is:
(a)	for a Part 2 registration, (in a first registration case) the last day of the period of one year beginning on the date of registration, or (in a renewal case) the last day of the period of ten years beginning on the date of renewal;
(b)	for a Part 3 registration, the last day of the period of 5 years beginning on the date of registration or renewal.]

The applicant may apply as an existing operator if:
(a)	the answer to questions 1, 3, 7 and 8 is ‘Yes’ OR
(b)	the answer to questions 1, 4, 7 and 8 is ‘Yes’ OR
(c)	the answer to questions 5, 7 and 8 is ‘Yes’ AND
-	the answer to question 6 is ‘Part 2 Registration’ and the applicant is applying for a club gaming permit; OR
-	the answer to question 6 is ‘Part 3 Registration’ and the applicant is applying for a club machine permit.

If the applicant is applying as an existing operator:
•	Do NOT complete SECTION C
•	Relevant documentation must be provided – see SECTION H
•	A different application fee is payable for an existing operator.	
SECTION C – Fast-track Procedure
[This section does not apply to Scotland]

9.	Please indicate if this application is made under the fast-track procedure [tick as appropriate]: Yes	No	[to apply under the fast-track procedure, the applicant must be the holder of a club premises certificate under section 72 of the Licensing Act 2003]

10.	If the answer to question 9 is ‘Yes’, please complete the declaration below:

‘I hereby certify that the applicant for a permit is the holder of a club premises certificate under	

section 72 of the Licensing Act 2003’

Full Name	

Signature	
Capacity

If the answer to question 9 is ‘Yes’ relevant documentation must be provided – see SECTION H	
SECTION D – Details of the Applicant

11.	Name of applicant

12.	Address (including postcode) of premises on which the applicant operates	
[any gaming or gaming machines authorised by a relevant permit must take place or be located on these premises]	
SECTION E – Information about the Applicant

If the applicant is a miners’ welfare institute, complete questions 13 to 16:

13.	Is the applicant established and conducted for social and recreational purposes? Yes	No

14.	Are the applicant’s affairs managed by a group of individuals of whom at least two thirds are miners’ representatives? Yes	No

15.	Does the applicant operate on premises the use of which is regulated in accordance with a charitable trust? Yes	No

16.	If the answer to question 15 is ‘Yes’, has the charitable trust received money from any of the following:
(a)	the Miners’ Welfare Fund established by section 20 of the Mining Industry Act 1920,
(b)	the former body corporate which was known as the Coal Industry Social Welfare Organisation and incorporated under the Companies Act 1948, or
(c)	the charitable trust known as the Coal Industry Social Welfare Organisation? Yes	No	

If the applicant is a members’ club or commercial club, complete questions 17 to 22

17.	Is the applicant established with the purpose of functioning only for a limited period of time? Yes	No

18.	Does the applicant have at least 25 individual members? Yes	No

19.	Is the applicant established and conducted for the benefit of its members? Yes	No

20.	Is the applicant established or conducted as a commercial enterprise? Yes	No

21.	Describe the purpose(s) for which the applicant is wholly or mainly established and conducted	
22. If the applicant is established or conducted wholly or mainly for the purpose of the provision of facilities for gaming, please specify the kinds of gaming	
SECTION F – General information about person completing this application form on behalf of applicant

23.	Name

24.	Capacity

25.	Address (including postcode)	

SECTION G – Contact details for correspondence associated with this application

26. Please tick one box as appropriate:

Address in section D	Address in section F	Address below	: Address (including postcode)	
Telephone number

E-mail address (if the applicant is happy for correspondence in relation to this application to be sent via e-mail)	
SECTION H – Declaration

27. Please complete the following declarations and checklist: I [full name]
a.	make this application on behalf of the applicant and have authority to act on behalf of the applicant.

b.	confirm that I am aware of any relevant provision of a code of practice issued by the Gambling Commission under section 24 of the Gambling Act 2005 about the location and operation of a gaming machine.

c.	confirm that I am aware that the permit to which this application relates will be subject to the relevant conditions specified in section 271 or 273 of the Gambling Act 2005.

d.	confirm that I am aware that (unless this application is made under the fast-track procedure) the applicant must send a copy of this application and any accompanying documents to the Gambling Commission and the chief officer of police (or chief constable in Scotland) within a period of seven days beginning on the date this application is made.

e.	confirm that, to the best of my knowledge, the information contained in this application is true. I 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.

Checklist [tick as appropriate]:

Payment of the appropriate fee of £	is enclosed.
A copy of the existing club gaming permit or club machine permit is enclosed [only applies to applications to renew a permit]
A copy of the registration certificate issued under Part 2 of the Gaming Act 1968 is enclosed	

[only applies if the applicant wishes to apply as an existing Part 2 operator]
A copy of the registration certificate issued under Part 3 of the Gaming Act 1968 is enclosed
[only applies if the applicant wishes to apply as an existing Part 3 operator]
The applicant’s club premises certificate issued under section 72 of the Licensing Act 2003 is enclosed [only applies if the applicant has completed the declaration in section C]	

Signature	
Date Capacity	

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