Notification of an interest in premises under section 178 of 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/We 	     	
(Insert name(s) of notifier)		
hereby give/gives notice of my/our interest in the premises identified below for the purposes of  section 178 of the Licensing Act 2003	
	
Part 1 – Premises details  
	
Postal address of premises or, if none, ordnance survey map reference or description
     	
Post town        
	Post code          	

Name of applicant for, or holder of, premises licence or club applying for, or holding, club premises certificate (if known)	
	
     	

Premises licence / club premises certificate number (if known)
	
     	

Part 2 - Details of my/our interest in the premises
	
I/we 	Please tick	
	
	a)	have a legal interest in the premises as freeholder or leaseholder		
	
	b)	am/are the  legal mortgagee in respect of the premises (within the meaning of the Law of Property Act 1925)		
	
	c)	am/are in occupation of the premises		
	
I /we are
	
	a)	an individual(s)	  please complete section (A)	
	
	b) 	a company	  please complete section (B)	
	
	c) 	a partnership	  please complete section (B)	
	
	d) 	an unincorporated association	  please complete section (B)	
	
	e)  	other (for example, a statutory corporation)	  please complete section (B)	
	
(A) DETAILS OF INDIVIDUAL 
	
Please tick		
Mr		Mrs		Miss		Ms		Other title	     	
	(for example, Rev)	
	
Surname   		First names	
     
		     	
	
Current postal 
address if 
different from premises address
	     	
	
Post Town	     	Postcode	     	
	
Contact phone number in working hours (if any)	     	
	
E-mail address (optional)

(optional)
	     	

DETAILS OF SECOND INDIVIDUAL 
	
Please tick	
Mr		Mrs		Miss		Ms		Other title 	     	
	(for example, Rev)	
Surname   		First names	
     
		     	
	
Current postal 
address if 
different from premises address
	     	
	
Post Town	     	Postcode	     	
	
Contact phone number in working hours (if any)	     	
	
E-mail address (optional)

(optional)
	     	
	
(B)  DETAILS OF NON-INDIVIDUAL 
	
Please provide name and registered address of notifier in full. Where appropriate please give any registered number. In the case of a partnership or other joint venture (other than a body corporate), please give the name and address of each party concerned	
	
Name

     	
Address
     	
Registered number (where applicable)
     	
Description of applicant (for example partnership, company, unincorporated association etc)
     	
Telephone number (if any)
     	
E-mail address (optional)
     	

Please tick yes	
•	I have made or enclosed payment of the fee 		
	
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 NOTIFICATION	
	
Part 3 – Signatures   (please read guidance note 1)

Our full environmental health privacy policy is available at https://www.cambridge.gov.uk/media/6335/environmental-health-privacy-notice.pdf

Signature of notifier or notifier’s solicitor or other duly authorised agent (See guidance note 2).  If signing on behalf of the notifier please state in what capacity.	
	
Signature     
…………………………………………………………………………………………………	
	
Date                  
…………………………………………………………………………………………………	
	
Capacity           
…………………………………………………………………………………………………	
For joint notifiers signature of 2nd notifier 2nd notifier’s solicitor or other authorised agent  (please read guidance note 3).  If signing on behalf of the notifier please state in what capacity.	
	
Signature     
…………………………………………………………………………………………………	
	
Date                  
…………………………………………………………………………………………………	
	
Capacity           
…………………………………………………………………………………………………	

Contact name (where not previously given or where it differs from the notifier) and address for correspondence associated with this notification (please read guidance note 4)

     	
Post town        	Post Code         	
Telephone number (if any)
     	
E-mail address (optional)
     	
	
Notes for Guidance 

1.	The form must be signed.
2.	A notifier’s agent (for example solicitor) may sign the form on their behalf provided that they have actual authority to do so.
3.	Where there is more than one notifier, both notifiers or their respective agents must sign the form.
4.	This is the address which we shall use to correspond with you about this notification and if a change is made to the register.
	
Acknowledgement by ………………………………………………………………………
                                       [insert name of relevant licensing authority]	
of receipt of this notification of an interest in the premises described in the 	
notice by the person/persons identified in the notice dated this ………. day  of 	
……………………….	20 [      ].	
Signed for and on behalf of the authority ..................................……………………..