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Application to vary a premises licence to specify an individual as designated premises supervisor under the Licensing Act 2003

Isle of Wight Council

	Application to vary a premises licence to specify an individual as designated premises supervisor under the Licensing Act 2003
	Environmental Health Isle of Wight Council Jubilee Stores The Quay Newport Isle of Wight PO30 2EH

The giving of false information may result in the licence 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This licence fee is not refundable in the event of the application being refused or withdrawn.

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

The Licence fee of Pay_180will be required when submitting this application.

Your Details

	Title
*	Forename
	Middle name/Initials
*	Surname

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

I/We ..................................................(full name(s) of premises licence holder) being the premises licence holder, apply to vary a premises licence to specify the individual named in this application as the premises supervisor under section 37 of the Licensing Act 2003

Part 1 - Premises details

Premises licence number

	Building name/number
	Street
	Town
	County
	Postcode
	If no postal address please provide ordnance survey map reference
	Telephone number (include area code)
	Please give a brief description of the premises (please read guidance note 1)

Part 2

Full name of proposed designated premises supervisor

Personal licence number of proposed designated premises supervisor and issuing authority of that licence (if any)

Full name of existing designated premises supervisor (if any)

I would like this application to have immediate effect under section 38 of the Licensing Act 2003 (Please tick if YES)

I have enclosed the premises licence or relevant part of it(Please tick if YES)

(If you have not enclosed the premises licence, or relevant part of it, please give reasons why not below)

Yes No

Reasons why I have failed to enclose the premises licence or relevant part of it

Checklist

I have made or enclosed payment of the fee

I will give a copy of this application to the chief officer of police

I have enclosed the consent form completed by the proposed premises supervisor

I have enclosed the premises licence, or relevant part of it or explanation

I will give a copy of this form to the existing premises supervisor, if any

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

	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 APPLICATION

Signatures

	Signature of applicant or applicant's solicitor or other duly authorised agent (See guidance note 3). If signing on behalf of the applicant please state in what capacity.	Signed ............................................................................... Name................................................................................. Date................................................................................... Capacity............................................................................
	For joint applicants signature of 2nd applicant 2nd applicant's solicitor or other authorised agent (please read guidance note 4). If signing on behalf of the applicant please state in what capacity.	Signed ............................................................................... Name................................................................................. Date................................................................................... Capacity............................................................................

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.

Contact details for correspondence associated with this application (if different from "Your Details" page 1)

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

*Yes

	Title
	Forename
	Middle name/Initials
	Surname

	Building/house name/number
	Street
	Town
	County
	Postcode
	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

For all communications regarding this form please quote the following reference information

	Reference number:
	Date of submission:
	Payment Reference Number:
	CRM Ref No:

	Product	Cost	VAT code	GL Code
	Change to Designated Premises Supervisor Fee	£23.00	AN	67605732501

Date printed: 07/03/2013