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

PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST

Before completing this form please read the guidance notes at the end of the form.
If you are completing this form by hand please write legibly in block capitals. In all cases ensure that your answers are inside the boxes and written in black ink. Use additional sheets if necessary.
You may wish to keep a copy of the completed form for your records. 
	
I 	     	
  (Insert name of applicant)	
apply for the review of a premises licence under section 51 / apply for the review of a club premises certificate under section 87 of the Licensing Act 2003 for the premises described in Part 1 below (delete as applicable)	
	
Part 1 – Premises or club premises details  	
Postal address of premises or, if none, ordnance survey map reference or description
     	
Post town        	Post code (if known)       	
	
Name of premises licence holder or club holding club premises certificate (if known)
     	
	
Number of premises licence or club premises certificate (if known 
     	

Part 2 - Applicant details 	
I am 	
	Please tick yes	
1)	an interested party (please complete (A) or (B) below)

a)	a person living in the vicinity of the premises

b)	a body representing persons living in the vicinity of the premises

c)	a person involved in business in the vicinity of the premises

d)	a body representing persons involved in business in the vicinity of the premises	 	
1)			
1)			
1)			
1)			
	
2)	a responsible authority (please complete (C) below)		
	
3)	a member of the club to which this application relates (please complete (A) below)	   	

(A) DETAILS OF INDIVIDUAL APPLICANT (fill in as applicable)
	
Please tick	
Mr		Mrs		Miss		Ms		Other title	     	
	(for example, Rev)	
	
Surname		First names	
     		     	
	
	Please tick yes	
I am 18 years old or over

Current postal 
address if 
different from premises address	     	
	
Post town	     	Post Code	     	
	
Daytime contact telephone number	     	
	
E-mail address (optional) 	     	

(B)  DETAILS OF OTHER APPLICANT	
	
Name and address
     	
Telephone number (if any)
     	
E-mail address (optional) 
     	

 (C)  DETAILS OF RESPONSIBLE AUTHORITY APPLICANT

Name and address
     	
Telephone number (if any)
     	
E-mail address (optional) 
     	

This application to review relates to the following licensing objective(s)	
	Please tick one or more boxes	
1)	the prevention of crime and disorder		
2)	public safety		
3)	the prevention of public nuisance		
4)	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)

     	

Please tick yes	
Have you made an application for review relating to this premises before		
	
If yes please state the date of that application	Day	
Month	
Year	

 	
 	
 	
 	
 	
 	
 	
 	

	

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

	
Please tick yes	
•	I have sent copies of this form and enclosures to the responsible authorities and the premises licence holder or club holding the club premises certificate, 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   (please read guidance note 3)	
	
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.	
	
Signature     
…………………………………………………………………………………………………	
	
Date                  
…………………………………………………………………………………………………	
	
Capacity           
…………………………………………………………………………………………………	

Contact name (where not previously given) and postal address for correspondence associated with this application (please read guidance note 5)
     	
Post town
     	Post Code
     	
Telephone number (if any)       	
If you would prefer us to correspond with you using an e-mail address your e-mail address (optional)      	

Notes for Guidance
1.	The ground(s) for review must be based on one of the licensing objectives.
2.	Please list any additional information or details for example dates of problems which are included in the grounds for review if available.
3.	The application form must be signed.
4.	An applicant’s agent (for example solicitor) may sign the form on their behalf provided that they have actual authority to do so.
5.	This is the address which we shall use to correspond with you about this application.

Licensing, Environmental Services, Cambridge City Council, PO Box 700, Cambridge, CB1 0JH