Application to renew a personal licence
	Environmental Health Isle of Wight Council Jubilee Stores The Quay Newport Isle of Wight PO30 2EH

*	The giving of false information may result in registration being refused or revoked, and the local authority reserve the right to make such further enquiries arising out of this application as they may consider desirable. This licence fee is not refundable in the event of the application being refused or otherwise. Please tick this box to confirm you have read and accept these terms and conditions
	PLEASE NOTE: Information on the Licensing Act 2003 is available on the website of the Department for Culture, Media and Sport (http://www.culture.gov.uk/alcohol_and_entertainment/default.htm) or from your local licensing authority.
	The Licence fee of   will be required when submitting this application

Your personal details

*

Title

--- Mrs Mr Miss Ms Sir Lord Lady Dr Prof Rev Other

Other title (please specify)

*	Forename
	Middle name/Initials
*	Surname
	Previous names (please enter details of any previous names or maiden names, if applicable)

	Address where you are ordinarily resident
	We will use this address to correspond with you unless you indicate otherwise by also completing the separate correspondence box below.

*	Building/house name/number
*	Street
*	Town
*	County
*	Postcode