Notification of an Interest In Premises The Licensing Act 2003 (Premises Licence and Club Premises Certificate) Regulations 2005. Regulation 9/Schedule 1

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Notification of an Interest In Premises
This form can be completed on-line.
Before completing this form please read the guidance notes below. Use additional sheets if necessary. You may wish to keep a copy of the completed form for your records.
Guidance Notes
1. The application form must be signed.
2. A notifier’s agent (for example solicitor) may sign the form on their behalf provided that they have actual authority to do so.
3. Where there is more than one notifier, with either Notifiers or their respective agents must sign the application form.
4. This is the address that we shall use to correspond with you about this application.
The fee for this application is £21 and must be included with the submission of the application.
Once PRINTED please ensure the form is signed and sent to the Council
Schedule 1: Notification of an interest in premises under section 178 of the Licensing Act 2003
Enter Notifiers Name
I/We
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hereby give/gives notice of my/our interest in the premises identified below for the purpose of section 178 of the Licensing Act 2003.
Part 1 - Premises details
Postal address of premises or if none, ordnance survey map reference or description
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Name of the 'APPLICANT for' OR 'HOLDER of' premises licence, or club applying for or holding, club premises certificate (if known)
Premises Licence Number or Club Premises Certificate Number (if known)