Kirklees Council, Licensing, Flint Street Depot, Flint Street, Fartown, Huddersfield HD1 6LG

		

APPLICATION FOR THE GRANT I CHANGE OF NAME OF AN UNLICENSED FAMILY ENTERTAINMENT CENTRE GAMING MACHINE PERMIT
(FOR USE BY OCCUPIERS I PROPOSED OCCUPIERS OF PREMISES INTENDED TO BE USED BY THE APPLICANT AS UNLICENSED FAMILY ENTERTAINMENT CENTRES)

Section D -General Information

8. Name of premises ............................................................................................................................. .

9. Address of premises .......................................................................................................................... .

10. Telephone number of premises ............................................................................................................   .

11. Name of applicant

12.	Address of applicant

13.	Telephone number (daytime) of applicant

14.	E-mail address of applicant

15.	Name, address, telephone and e-mail of agent (e.g. solicitor) if submitted on behalf of the applicant

Section E- Fee and Signature(s)

Ienclose a sum of£........ (cheques should be made payable to....................)                                     D

I confirm that I occupy Ipropose to occupy the premises to which this application relates.            D

I confirm that I am 18 years of age or older.                                                                                   D

Please note: It is an offence under section 342 of the Gambling Act 2005 if a person. without reasonable excuse. gives to a licensing authoritr for a pumose connected with that Act information which is false or misleading.

Dated ...............................................................................................................................................    .

Signed (by or on behalf of applicant I permit holder).............................................................................. .

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

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