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
layout of premises should also be included with your application) Are you the owner of these premises YES/NO (please delete as applicable) If NO, have you included a letter of consent from the of the premises (this is required for use of land owned either privately or by a public authority) which permits you to use premises for your intended purpose: YES/NO (delete as applicable) If NO – your application cannot be processed such time as said letter of consent is obtained and forwarded OR Please specify the days and times it is proposed that the premises will be open (24 hour format) Days: Times: Details of proposed operation: Carryout / Restaurant / Carryout only Type of Food to be sold: 8. I declare I shall for a period of 21 days beginning with the date on which the application is submitted to the licensing authority display the “Notice for Posting” at or near the premises to be licensed. OR I declare that I am unable to display the “Notice for Posting” because I do not have such rights of access or other rights in respect of the premises as are required for me to do so, but that I have taken such reasonable steps as are open to me to acquire them. The steps I have taken to acquire these rights are: Declaration and Information: I declare that the particulars given by me on this form are true and I hereby make application to Argyll and Bute Council for the grant of the licence applied for above. I understand that I, or any person who, in connection with the making of this application makes any statement which I/they know to be false or recklessly makes any statement which is false in a material particular shall be guilty of an offence and liable, on summary conviction, to a fine not exceeding £2500.00. I also confirm that, if granted a licence, I will comply fully with the conditions of that licence and have, previous to lodging this application, made myself familiar with the terms of Argyll and Bute Councils’ standard conditions pertaining to the licence. Signature of Applicant: Note – Please ensure your signature is within the marked box. Date: Notes: 1. Any form lodged which has not been fully completed will be considered incompetent and returned to the applicant.