All fields marked with a * are required entries
Application for a Personal Licence
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Application for a Personal Licence
Environmental Health
Isle of Wight Council
Jubilee Stores
The Quay
Newport
Isle of Wight
PO30 2EH
Please Note:
A Disclosure of Convictions and Declaration form
must also be submitted along with this form.
*
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.
The Licence fee is not refundable should the application be withdrawn or refused.
Please tick this box to confirm you have read and accept these terms and conditions
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
*
Have you ever used another name?
Yes
No
Previous names
(please enter details of any previous names or maiden names if applicable)
*
I am 18 years old or over
Yes
No
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
Fields marked '*' are required entries.
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