Application to vary a premises licence under the Licensing Act 2003

	Environmental Health Isle of Wight Council Jubilee Stores The Quay Newport Isle of Wight PO30 2EH
	Before completing this form please click here to read the guidance notes. Please click here to view the fee structure under the Licensing Act 2003. You may wish to keep a copy of the completed form for your records. Please Note: A Designated Premises Supervisor (DPS) Consent form must also be submitted along with this form, but only if the DPS is changing.

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The Licence fee is not refundable should the application be withdrawn or refused.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

*	Band A. Band B. Band C. Band D. Band E.	A)	A) For premises with no rateable value to £4,300
		B)	B) For premises with rateable value from £4,301 to £33,000
		C)	C) For premises with a rateable value of £33,001 to £87,000
		D)	D) For premises with a rateable value from £87,001 to £125,000
		E)	E) For premises with a rateable value of £125,001 and above

Your details

*	Forename
	Middle name/Initials
*	Surname

*	Building/house name/number
*	Street address
*	Town name
	County
*	Postcode
	Tel number (include area code)
	Email address
	Fax