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Notification of an interest in premises under section 178 of the Licensing Act 2003

Isle of Wight Council

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.

Please tick this box to confirm you have read and accept these terms and conditions

The Licence fee of £21.00 will be required when submitting this application.

Your Details

Title

* Forename

Middle name/Initials

* Surname

* Building/house name/number

* Street address

* Town name

* County

* Postcode

* Telephone number
(include area code)

* Email address

Fax

* I/We (Insert name(s) of notifier) hereby give/gives notice of my/our interest in the premises identified below for the purposes of section 178 of the Licensing Act 2003

Part 1 - Premises details

Premises licence / club premises certificate number (if known)

Building name/number

Street

Town

County

Postcode

If no postal address please provide ordnance survey map reference or description

Name of applicant for, or holder of, premises licence or club applying for, or holding, club premises certificate (if known)

Part 2 - Details of my/our interest in the premises

I/we:

have a legal interest in the premises as freeholder or leaseholder

am/are the legal mortgagee in respect of the premises (within the meaning of the Law of Property Act 1925)

am/are in occupation of the premises

I /we are

an individual(s)- please complete section A

a company - Please complete section B

a partnership - please complete section B

an unincorporated association - please complete section B

other (for example, a statutory corporation) - please complete section B

Are you applying as an individual?

Yes No

If 'No' please click here to go to Section B

Section A - Details of individual

Title

Forename

Middle name/Initials

Surname

Current postal address if different from premises address

(include Post Town and Postcode)

Contact phone number in working hours (if any)

E-mail address

Details of Second Individual

Title

Forename

Middle name/Initials

Surname

Current postal address if different from premises address

Contact phone number in working hours (if any)

E-mail address (optional)

Section B - Details of Non-individual

Please provide name and registered address of notifier in full. Where appropriate please give any registered number. In the case of a partnership or other joint venture (other than a body corporate), please give the name and address of each party concerned

Name

Building name/number

Street

Town

County

Postcode

Telephone number (if any)

E-mail address (optional)

In the case of a partnership or other joint venture (other than a body corporate), please give further names and addresses of each party concerned here

Registered number (where applicable)

Description of applicant (for example partnership, company, unincorporated association etc)

* Checklist

I have made or enclosed payment of the fee.

If not submitting this form online, please make your cheque payable to Isle of Wight Council.

IT IS AN OFFENCE, LIABLE ON CONVICTION TO A FINE UP TO LEVEL 5 ON THE STANDARD SCALE , UNDER SECTION 158 OF THE LICENSING ACT 2003 TO MAKE A FALSE STATEMENT IN OR IN CONNECTION WITH THIS NOTIFICATION

Part 3 - Signatures (please read guidance note 1)

Signature of notifier or notifier's solicitor or other duly authorised agent (See guidance note 2).

If signing on behalf of the notifier please state in what capacity.

Signed ...............................................................................

Name.................................................................................

Date...................................................................................

Capacity.............................................................................

For joint notifiers signature of 2nd notifier 2nd notifiers solicitor or other authorised agent (please read guidance note 3). If signing on behalf of the notifier please state in what capacity.

Signed ...............................................................................

Name.................................................................................

Date...................................................................................

Capacity.............................................................................

This form must be signed and presented to the licensing section before a decision is made and the licence may be granted. Either print off the completed form, sign and post to the licensing department or attend council offices to sign after you have submitted the form online.

This application fee is not refundable in the event of the application being refused or otherwise.

Acknowledgement by the licensing authority

Acknowledgement by [insert name of relevant licensing authority] of receipt of this notification of an interest in the premises described in the notice by the person/persons identified in the notice dated this day of 20

Signed ...............................................................................

(for and on behalf of the authority)

Name.................................................................................

Date...................................................................................

Data Protection Act 1998

This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request.

The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest.

Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law.

Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box

To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

	Product	Cost	VAT code	GL Code
	Notification of Interest fee	£21.00	AN	67605732501

Date printed: 07/03/2013

	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

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

	Premises licence / club premises certificate number (if known)
	Building name/number
	Street
	Town
	County
	Postcode
	If no postal address please provide ordnance survey map reference or description
	Name of applicant for, or holder of, premises licence or club applying for, or holding, club premises certificate (if known)

	If 'No' please click here to go to Section B
	Section A - Details of individual

	Current postal address if different from premises address (include Post Town and Postcode)
	Contact phone number in working hours (if any)
	E-mail address

	Title
	Forename
	Middle name/Initials
	Surname
	Current postal address if different from premises address
	Contact phone number in working hours (if any)
	E-mail address (optional)

	Section B - Details of Non-individual
	Please provide name and registered address of notifier in full. Where appropriate please give any registered number. In the case of a partnership or other joint venture (other than a body corporate), please give the name and address of each party concerned

	In the case of a partnership or other joint venture (other than a body corporate), please give further names and addresses of each party concerned here
	Registered number (where applicable)
	Description of applicant (for example partnership, company, unincorporated association etc)

	If not submitting this form online, please make your cheque payable to Isle of Wight Council.
	IT IS AN OFFENCE, LIABLE ON CONVICTION TO A FINE UP TO LEVEL 5 ON THE STANDARD SCALE , UNDER SECTION 158 OF THE LICENSING ACT 2003 TO MAKE A FALSE STATEMENT IN OR IN CONNECTION WITH THIS NOTIFICATION

	Signature of notifier or notifier's solicitor or other duly authorised agent (See guidance note 2). If signing on behalf of the notifier please state in what capacity.	Signed ............................................................................... Name................................................................................. Date................................................................................... Capacity.............................................................................
	For joint notifiers signature of 2nd notifier 2nd notifiers solicitor or other authorised agent (please read guidance note 3). If signing on behalf of the notifier please state in what capacity.	Signed ............................................................................... Name................................................................................. Date................................................................................... Capacity.............................................................................

	Acknowledgement by the licensing authority
	Acknowledgement by [insert name of relevant licensing authority] of receipt of this notification of an interest in the premises described in the notice by the person/persons identified in the notice dated this day of 20 Signed ............................................................................... (for and on behalf of the authority) Name................................................................................. Date...................................................................................