Licensing Department

Application for the review of a premises licence or club premises certificate under the Licensing Act 2003

PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST

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.

I

(Insert name of applicant)
apply for the review of a premises licence under section 51 / apply for the review of a club premises certificate under section 87 of the Licensing Act 2003 for the premises described in Part 1 below (delete as applicable)

Part 1	Premises or club premises details

Postal address of premises or, if none, ordnance survey map reference or description	
Post town	Post code (if known)	

Name of premises licence holder or club holding club premises certificate (if known)

Number of premises licence or club premises certificate (if known)

Part 2 - Applicant details

I am

Please tick	yes

1)	an individual, body or business which is not a responsible authority (please read guidance note 1, and complete (A)
or (B) below)

2)	a responsible authority (please complete (C) below)

3)	a member of the club to which this application relates (please complete (A) below)

(A)	DETAILS OF INDIVIDUAL APPLICANT (fill in as applicable) Please tick	yes
Mr	Mrs	Miss	Ms	Other title
(for example, Rev)

Surname	First names

I am 18 years old or over

Please tick	yes

Current postal address if different from premises address

Post town	Post Code

Daytime contact telephone number

E-mail address (optional)

(B)	DETAILS OF OTHER APPLICANT

Name and address	
Telephone number (if any)	
E-mail address (optional)	

(C)	DETAILS OF RESPONSIBLE AUTHORITY APPLICANT

Name and address	
Telephone number (if any)	
E-mail address (optional)	

This application to review relates to the following licensing objective(s)

1)	the prevention of crime and disorder
2)	public safety
3)	the prevention of public nuisance
4)	the protection of children from harm

Please tick one or more boxes

Please state the ground(s) for review (please read guidance note 2)

Please provide as much information as possible to support the application (please read guidance note 3)

Have you made an application for review relating to the premises before

Please tick	yes

If yes please state the date of that application	Day	Month	Year

If you have made representations before relating to the premises please state what they were and when you made them

Please tick	yes

   I have sent copies of this form and enclosures to the responsible authorities and the premises licence holder or club holding the club premises certificate, as appropriate
   I understand that if I do not comply with the above requirements my application will be rejected

IT IS AN OFFENCE, LIABLE ON CONVICTION TO A FINE UP TO LEVEL 5 ON THE STANDARD SCALE, UNDER SECTION 158 OF THE LICENSING ACT 2003 TO MAKE A FALSE STATEMENT IN OR IN CONNECTION WITH THIS APPLICATION

Part 3    Signatures   (please read guidance note 4)

 (please read guidance note 5). If signing on behalf of the applicant please state in what capacity.

Signature Date Capacity

Contact name (where not previously given) and postal address for correspondence associated with this application (please read guidance note 6)	
Post town	Post Code	
Telephone number (if any)	
If you would prefer us to correspond with you using an e-mail address your e-mail address (optional)	

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

Notes for Guidance

1.	A responsible authority includes the local police, fire and rescue authority and other statutory bodies which exercise specific functions in the local area.
2.	The ground(s) for review must be based on one of the licensing objectives.
3.	Please list any additional information or details for example dates of problems which are included in the grounds for review if available.
4.	The application form must be signed. 5.
that they have actual authority to do so.
6.	This is the address which we shall use to correspond with you about this application.

Kirklees Licensing Department, Flint Street, Depot, Flint Street, Huddersfield HD1 6LG