REQUEST TO BE REMOVED AS DESIGNATED PREMISES SUPERVISOR UNDER THE LICENSING ACT 2003	

If you are completing this form by hand please write legibly in block capitals. In all cases ensure 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 ___________________________________________being the Designated Premises Supervisor, notify Cambridge City Council, Licensing Authority of my wish to cease being the Designated Premises Supervisor under Section 41 of the Licensing Act 2003 with effect from: 
Date: _______________ 		Time: _______________ 
PART 1 – PREMISES DETAILS 
Name of Premises:	
Address of Premises:
	
Telephone number:	

Premises Licence number (if known) PRECAM:	

Description of Premises	

	

PART 2 – DESIGNATED PREMISES SUPERVISOR DETAILS 
Full name & address of outgoing Designated Premises Supervisor:
	
Personal Licence Number:	
Issuing Authority: 	

NOTE: Please complete Section A if you are the Premises Licence Holder – if not, please complete Section B.
Section A
Please tick √ yes 
I have enclosed the Premises Licence or relevant part 			□ 
OR 
I have provided reasons why I have failed to enclose the			 □ premises licence or relevant part.
I am aware that, under Section 56, paragraph 2 – 4 of the 			□ Licensing Act 2003, it is a relevant offence if I fail, without 
Reasonable excuse, to comply with the requirement to Produce
my existing licence.
I understand that if I do not comply with the above 				□ requirements my notification will be rejected. 
Reasons why I have failed to enclose Premises Licence or relevant part of it	

	

Section B - Declaration 							Please tick yes 
1) I am not the Premises Licence Holder; 						□ 
2) I understand that I am obliged to serve a copy of this notice 			□ on the Premises Licence Holder within 48 hours after the date
of my giving the notice to the Cambridge City Council; 
3) I understand that I must serve a notice on the Premises Licence 			□ Holder directing them to send to Cambridge City Council within 14 days of receiving this notice: 
(i) the Premises Licence (or appropriate part of the licence) or
(ii) if that is not practicable, a statement of the reasons for the failure to provide the licence (part); 
4) I am aware that, under Section 41, paragraph 5 of the Licensing 			□ Act 2003, it is a relevant offence if I fail, without reasonable excuse to comply with these requirements; 
5) I understand that if I do not comply with the above requirements 			□ my notification will be rejected; 
NOTE: 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. 
Signature of Outgoing Designated Premises Supervisor 

Signature: __________________________ Date: _________________

NOTICE TO A PREMISES LICENCE HOLDER 
Pursuant to section 41(4) the Licensing Act 2003	

To: 
Name of Premises Licence Holder: ______________________________ 
Address of Premises Licence Holder: ______________________________ 

Take notice that on ……………………. [insert date of notice] I gave notice pursuant to section 41(1) Licensing Act 2003 to Cambridge City Council, Licensing Authority of my wish to cease being the Designated Premises Supervisor for the premises detailed. A copy of that notice is attached. 
By this notice I direct you, as premises licence holder, to send to Cambridge City Council, Licensing Authority within 14 days of receiving this notice:-.
1. The premises licence (or the appropriate part of the licence) or 
2. If that is not practicable a statement of the reasons for the failure to provide the licence (or part). 
Take notice that if you fail to comply with this direction without reasonable excuse you will be guilty of an offence pursuant to section 41(5) of the Act and may be liable on summary conviction to a fine not exceeding level 3 on the standard scale. 
Signed: ________________________________ 
Print Name: ________________________________
Dated: ________________________________

CERTIFICATE OF SERVICE	

I …………………………………………………………………………………… 
[Insert name of Designated Premises Supervisor] 

of ……………………………………………………………………………………
[Insert address of Designated premises Supervisor] 

hereby certify that on ………………………………………….. [insert date of service]

I served ………………………………………………………………………………… 
……………………………………………………………………………………………
[insert name and address of premises holder] 

with a copy of a notice served by me upon Cambridge City Council, Licensing Authority pursuant to section 41(1) Licensing Act 2003 together with a notice pursuant to section 41(4)(b) of that Act 

by ………………………………………………………………………………………. 
[insert details of method of service e.g. personal delivery, recorded delivery etc.]