Isle of Wight Council

	Application to renew a personal licence
	Environmental Health Isle of Wight Council Jubilee Stores The Quay Newport Isle of Wight PO30 2EH

*	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
	PLEASE NOTE: Information on the Licensing Act 2003 is available on the website of the Department for Culture, Media and Sport (http://www.culture.gov.uk/alcohol_and_entertainment/default.htm) or from your local licensing authority.
	The Licence fee of £37.00 will be required when submitting this application

Your personal details

*	Title
*	Forename
	Middle name/Initials
*	Surname
	Previous names (please enter details of any previous names or maiden names, if applicable)

	Address where you are ordinarily resident
	We will use this address to correspond with you unless you indicate otherwise by also completing the separate correspondence box below.

*	Building/house name/number
*	Street
*	Town
*	County
*	Postcode

Contact details

	Telephone numbers (please provide area code)	daytime
		evening
		mobile

	Fax number
*	E-mail address
*	Please indicate if you would prefer us to correspond with you by email?	Yes No

Address for correspondence associated with this application (if different to the address given before)

	Building/house name/number
	Street
	Town
	County
	Postcode
	Telephone number (please provide area code)
	Fax

	Your current personal licence details
	Your personal licence must accompany your application for a renewal. If you are unable to send your personal licence, you must explain why you cannot do so in the box provided below.

*	Licensing Authority
*	Licence number
	Date of issue
	Date of expiry
	Any further details
	If you cannot provide your personal licence, provide a statement explaining why:

Other personal licences

*

I confirm that I do not hold any other personal licences other than the one submitted for renewal.

Yes No

I have: (Please tick 'yes' or 'no')

Checklist

	enclosed my current personal licence or a statement of the reasons of any failure to provide my licence	Yes No
	enclosed two photographs of myself, one of which is endorsed as a true likeness of me by a solicitor, notary, a person of standing in the community or any individual with a professional qualification	Yes No
	enclosed a criminal conviction certificate or a criminal record certificate or the results of a subject access search of the police national computer by the National Identification Service	Yes No
	enclosed a completed disclosure of criminal convictions and declaration form (Schedule 3)	Yes No
*	made or enclosed payment of the fee for the application	Yes No

Please click here to view the fee structure under the Licensing Act 2003.

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

	Declaration
	It is an offence knowingly or recklessly to make a false statement in or in connection with an application for the grant or renewal of a personal licence. (A person is to be treated as making a false statement if he produces, furnishes, signs or otherwise makes use of a document that contains a false statement). To do so could result in prosecution and a fine not exceeding level 5 on the standard scale.
	The information contained in this form is correct to the best of my knowledge and belief. Signed ............................................................................... Name.........................................................................(print) Date...................................................................................

You may wish to keep a copy of the completed form for your records.

	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