Application for a provisional statement under the Gambling Act 2005 (standard form) 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.

Where the application is in respect of a vessel the application should be made on the relevant form for that type of premises.

Regional Casino	Large Casino	Small Casino	
Bingo
Betting (Track)	Adult Gaming Centre Betting (Other)	Family Entertainment Centre	

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.	Proposed trading name to be used at the premises (if known):

11.	Address of the premises (or, if none, give a description of the premises or proposed premises and their location):

Postcode:
12.	Telephone number at premises (if known):

13.	If the premises are in only a part of a building, please describe the nature of the building (for example, a shopping centre or office block).  The description should include the number of floors within the building and the floor(s) on which the premises are located.

14(a) Are the premises or proposed premises situated in more than one licensing authority area? Yes/No [delete as appropriate]

14(b). If the answer to question 14(a) is yes, please give the names of all the licensing authorities within whose area the premises or proposed premises are partly located, other than the licensing authority to which this application is made:

15(a) Do you want the licensing authority to exclude a default condition so that the premises may be used for longer periods than would otherwise be the case?  Yes/No  [delete as appropriate] [Where the relevant kind of premises licence is not subject to any default conditions, the answer to this question will be no.]

15(b) If the answer to question 15(a) 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

16. If you want the premises licence to have a condition restricting gambling to specific periods in a year, please state the periods below using calendar dates:

17(a) Does the application relate to premises or proposed premises which are part of a track or other sporting venue which already has a premises licence:  Yes/No  [delete as appropriate]
17(b) If the answer to question 17(a) is yes, please confirm by ticking the box that an application to vary the main track premises licence has been submitted with this application:

18(a) Do you hold any other premises licences that have been issued by this licensing authority? Yes/No [delete as appropriate]

18(b) If the answer to question 18(a) is yes, please provide full details:

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

(Please tick)
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.

Checklist:
Payment of the appropriate fee has been made/is enclosed A plan of the premises or proposed premises is enclosed
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 20 and 21.]

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

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

22(b) Please give one or more telephone numbers at which the person identified in question 22(a) can be contacted:

23.	Postal address for correspondence associated with this application:

Postcode:

24.	
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: