Application for extended hours

Premises Licence Number

Premises Details

Name of Premises

Address

Address 2

City/Town

Post Code

Telephone number

E-mail Address

Licence Holder Details

Title

First Name

Surname

Is the licence holder's address different from the premises address noted above

Yes

Licence holders Address

Address

Address 2

City/Town

Post Code

Details of the special event or occasion

Current Licensed Hours

Opening Time

Closing Time

Proposed Extended Hours

From

What is the proposed period during which the extended hours will apply?

From Date

To Date

Please Note: This must not exceed one month

Does the extended hours proposal affect existing provisions for children /young persons?

Yes

Please provide details of measures to protect children from harm during any extended hours granted

Declaration

The fee of £10.00 must be submitted with this application.

I declare that the contents of this application form are true to the best of my knowledge

Submitted By

The information you have supplied on this form will be used for the purpose for which you have provided it, and appropriate measures are in place to protect your personal data. A full privacy notice, which provides information about your rights under current data protection legislation and details about what will happen to your personal data can be found here:

Privacy Notice - Liquor Licensing

��ֱ��

Services