Declaration for a club premises certificate to be granted under the Licensing Act 2003

ALL FIELDS MARKED WITH A * ARE REQUIRED ENTRIES

Licensing Act 2003

Please Note:

This form can be submitted online

YOU MUST BE LOGGED IN TO SAVE AND SUBMIT THIS FORM
You are not currently logged in to My Profile, however you may

Complete the form and obtain a printout at the end

If you log in you may

	Pre-populate certain details from your profile account
	Save your form at any time and complete it later
	Submit your form online.

New users click here to , existing users click here to

	Declaration for a club premises certificate to be granted under the Licensing Act 2003
	Environmental Health Isle of Wight Council Jubilee Stores The Quay Newport Isle of Wight PO30 2EH

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: An Application for a Club Premises Certificate must also be submitted along with this form.

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

Fields marked '*' are required entries.

Page 1 of 9

Print blank form

Clear all

Help

P19417

Close Window