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Application for the review of a premises licence under the Licensing Act 2003

Isle of Wight Council

	Application for the review of a premises licence under the Licensing Act 2003
	Environmental Health Isle of Wight Council Jubilee Stores The Quay Newport Isle of Wight PO30 2EH

I/We .................................................(Insert name of applicant) apply for the review of a premises licence under section 51 of the of the Licensing Act 2003 for the premises described in Part 1.

Part 1 - Premises Details

Premises licence number
(if known)

	Building name/number
	Street
	Town
	County
	Postcode
	If no postal address please provide ordnance survey map reference
	Name of premises licence holder (if known)

	Part 2 - Applicant details
	I am: (Please select the relevant box below)

1) an interested party:

(please click here to complete A or B below)

Interested Party - Person living in the vicinity of the premises

Interested Party - Body representing persons living in the vicinity

Interested Party - Person involved in a business in the vicinity

Interested Party - Body representing persons involved in the business

A Responsible Authority

A - Details of individual applicant

(fill in as applicable)

Applicant Type

Individual

Rep/Co or other

RA

	Title
*	Forename
	Middle name/Initials
*	Surname

I am 18 years old or over

Yes No

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

B - Details of other applicant

	Title
	Forename
	Middle name/Initials
	Surname

I am 18 years old or over

Yes No

	Building/house name/number
	Street address
	Town name
	County
	Postcode
	Day time telephone number (include area code)
	Email address
	Fax

C - Details of Responsible Authority Applicant

	Title
	Forename
	Middle name/Initials
	Surname

	Building/house name/number
	Street address
	Town name
	County
	Postcode
	Day time telephone number (include area code)
	Email address
	Fax

The Grounds for Review

This application to review relates to the following licensing

objective(s)

(please tick one or more boxes)

the prevention of crime and disorder

public safety

the prevention of public nuisance

the protection of children from harm

Please state the ground(s) for review
(please read guidance note 1)

Please provide as much information as possible to support the application

(please read guidance note 2)

Have you made an application for review relating to this premises before?

Yes No

If 'yes' please state the date of that application

(dd/mm/yyyy)

If you have made representations before relating to this premises please state what they were and when you made them

Checklist

I have sent copies of this form and enclosures to the responsible authorities and the premises licence holder, as appropriate.

I understand that if I do not comply with the above requirements my application will be rejected.

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 application.

	Part 3 - Signatures
	THIS FORM MUST BE SIGNED AND ALL THE RELEVANT DOCUMENTS, DETAILED ON THE FORM, SUBMITTED TO THE LICENSING SECTION BEFORE THE APPLICATION CAN BE PROCESSED. EITHER PRINT OFF THE COMPLETED FORM, SIGN AND POST TO THE LICENSING DEPARTMENT ALONG WITH THE REQUIRED DOCUMENTS OR ATTEND COUNCIL OFFICES AFTER YOU HAVE SUBMITTED THE FORM ONLINE.

Signature of applicant or applicant's solicitor or other duly authorised agent.

(See guidance note 4)

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

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

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

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

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

Is there an alternative contact name and address for correspondence associated with this application

*Yes

*If 'yes' please provide details:

	First Name
	Last Name

	Building/house name/number
	Street address
	Town name
	County
	Postcode
	Day time telephone number (include area code)
	Email address
	Fax

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

Date printed: 07/03/2013