Home Telephone: : Day Month Year Date of Birth Please give the name of the person responsible for the day to day running of business/managing the 4. activity. If this person is not one of those named above, please also give their address, date of birth and contact numbers: Full Name Home Address (Including Postcode) Day Month Year Home Telephone: : Date of Birth Criminal Convictions YES/NO 5. Subject to the provisions of the Rehabilitation of Offenders Act 1974, has any party named (please delete as above been convicted of any crime or offence in any Court in the United Kingdom? applicable) If YES, please give the following details: Date of Name: Convicting Court Details of Offence Sentence: Conviction: 1. 2. 3. Licences: 6. YES/NO Has, or do, any of the parties named above previously held, or currently hold, any type of (i) (please delete as Local Authority Licence? If YES, please give the following details: applicable) Name: Type of Licence: Date Granted: Expiry Date: Issuing Authority: 1. 2. 3. Has any of the parties named above, ever applied for any type of Local Authority Licence/s YES/NO (ii) and had their application refused: (please delete as applicable) If YES, please give the following details: Date of Name: Type of Licence: Authority Name: Reason for Refusal: Application: 1. 2. 3. 7. Activity/Premises Details: (i) Third Party Indemnity Insurance: Please give full details of the policy held (please also include a copy of this policy with your application): Policy Expiry Date: Premises: (ii) Where applicable, please give the name and address of the premises for which the licence is required. Please give details of the location of these premises (a sketch plan of the
Date of Birth Day Month Year Home Telephone: : 4. Please give the name of the person responsible for the day to day running of business/managing the activity. If this person is not one of those named above, please also give their address, date of birth and contact numbers: Full Name Home Address (Including Postcode) Date of Birth Day Month Year Home Telephone: : 5. Criminal Convictions Subject to the provisions of the Rehabilitation of Offenders Act 1974, has any party named above been convicted of any crime or offence in any Court in the United Kingdom? If YES, please give the following details: YES/NO (please delete as applicable) Name: Date of Conviction: Convicting Court Details of Offence Sentence: 1. 2. 3. 6. (i) Licences: Has, or do, any of the parties named above previously held, or currently hold, any type of Local Authority Licence? If YES, please give the following details: YES/NO (please delete as applicable) Name: Type of Licence: Date Granted: Expiry Date: Issuing Authority: 1. 2. 3. (ii) Has any of the parties named above, ever applied for any type of Local Authority Licence/s and had their application refused: YES/NO (please delete as applicable) If YES, please give the following details: Name: Type of Licence: Date of Application: Authority Name: Reason for Refusal: 1. 2. 3. 7. Activity/Premises Details: (i) Third Party Indemnity Insurance: Please give full details of the policy held (please also include a copy of this policy with your application): Policy Expiry Date: (ii) Premises: Where applicable, please give the name and address of the premises for which the licence is required. Please give details of the location of these premises (a sketch plan of the
civform_-_lhc_grant_4.docx