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Application for a provisional statement to be granted under the Licensing Act 2003
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Premises Details
I/We
apply for a premises licence under section 29 of the Licensing Act 2003 for the premises described in Part 1 below (the premises) and I/we are making this application to you as the relevant licensing authority in accordance with section 12 of the Licensing Act 2003
Postal address of premises, including postcode, or, if none, ordanance survey map reference or description
Telephone number of premises (if any)
a) an individual or individuals
b) a person other than an individual
i. as a limited company
ii. as a partnership
iii. as an unincorporated association or
iv. other (for example a statutory corporation)
c) a recognised club
d) a charity
e) the proprietor of an educational establishment
f) a health service body
g) a person who is registered under Part 2 of the Care Standards Act 2000 (c14) in respect of an independent hospital
h) the chief officer of police of a police force in England and Wales
If you are applying as a person described in (a) or (b) please confirm:
I am carrying on or proposing to carry on a business which involves the use of the premises for licensable activities;
I am making the application pursuant to a
statutory function or
a function discharged by virtue of Her Majesty’s prerogative
