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ALL FIELDS MARKED WITH A * ARE REQUIRED ENTRIES
 Licensing Act 2003

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Notification of an interest in premises under section 178 of 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.
* 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.
The Licence fee of   will be required when submitting this application.
Your Details
* Title Other title
(please specify)
* Forename
Middle name/Initials
* Surname
* Building/house name/number
* Street address
* Town name
* County
* Postcode
*  Telephone number
(include area code)

* Email address

Fax

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