Application For A Provisional Statement Under The Gambling Act

application for a provisional statement under the gambling act 2005 (standard form) =========================================================

Application for a provisional statement under the Gambling Act 2005
(standard form)
===================================================================
PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST
If you are completing this form by hand, please write legibly in block
capitals using ink. Use additional sheets if necessary (marked with
the number of the relevant question). You may wish to keep a copy of
the completed form for your records.
Where the application is in respect of a vessel the application should
be made on the relevant form for that type of premises.
Part 1 – Type of premises to which the application relates
Regional Casino
Large Casino
Small Casino
Bingo
Adult Gaming Centre
Family Entertainment Centre
Betting (Track)
Betting (Other)
Part 2 – Applicant Details
If you are an individual, please fill in Section A. If the application
is being made on behalf of an organisation (such as a company or
partnership), please fill in Section B.
Section A
Individual applicant
1. Title: Mr Mrs Miss Ms Dr Other (please specify)  
2. Surname:  
Other name(s):  
[Use the names given in the applicant’s operating licence or, if the
applicant does not hold an operating licence, as given in any
application for an operating licence]
3. Applicant’s address (home or business – [delete as appropriate]):
 
Postcode:  
4(a) The number of the applicant’s operating licence (as set out in
the operating licence):  
4(b) If the applicant does not hold an operating licence but is in the
process of applying for one, give the date on which the application
was made:  
5. Tick the box if the application is being made by more than one
person.
[Where there are further applicants, the information required in
questions 1 to 4 should be included on additional sheets attached to
this form, and those sheets should be clearly marked “Details of
further applicants”.]
Section B
Application on behalf of an organisation
6. Name of applicant business or organisation:
 
[Use the names given in the applicant’s operating licence or, if the
applicant does not hold an operating licence, as given in any
application for an operating licence]
7. The applicant’s registered or principal address:
 
Postcode:  
8(a) The number of the applicant’s operating licence (as given in the
operating licence):
 
8(b) If the applicant does not hold an operating licence but is in the
process of applying for one, give the date on which the application
was made:  
9. Tick the box if the application is being made by more than one
organisation.
[Where there are further applicants, the information required in
questions 6 to 8 should be included on additional sheets attached to
this form, and those sheets should be clearly marked “Details of
further applicants”.]
Part 3 – Premises Details
10. Proposed trading name to be used at the premises (if known):  
11. Address of the premises (or, if none, give a description of the
premises or proposed premises and their location):
 
Postcode:  
12. Telephone number at premises (if known): 
13. If the premises are in only a part of a building, please describe
the nature of the building (for example, a shopping centre or office
block). The description should include the number of floors within the
building and the floor(s) on which the premises are located.
 
14(a) Are the premises or proposed premises situated in more than one
licensing authority area?
Yes/No [delete as appropriate]
14(b). If the answer to question 14(a) is yes, please give the names
of all the licensing authorities within whose area the premises or
proposed premises are partly located, other than the licensing
authority to which this application is made:
 
Part 4 – Times of Operation
15(a) Do you want the licensing authority to exclude a default
condition so that the premises may be used for longer periods than
would otherwise be the case? Yes/No [delete as appropriate] [Where
the relevant kind of premises licence is not subject to any default
conditions, the answer to this question will be no.]
15(b) If the answer to question 15(a) is yes, please complete the
table below to indicate the times when you want the premises to be
available for use under the premises licence.
Start
Finish
Details of any seasonal variation
Mon
  hh:mm
  hh:mm
 
Tue
 
 
 
Wed
 
 
 
Thurs
 
 
 
Fri
 
 
 
Sat
 
 
 
Sun
 
 
 
16. If you want the premises licence to have a condition restricting
gambling to specific periods in a year, please state the periods below
using calendar dates:
 
Part 5 – Miscellaneous
17(a) Does the application relate to premises or proposed premises
which are part of a track or other sporting venue which already has a
premises licence: Yes/No [delete as appropriate]
17(b) If the answer to question 17(a) is yes, please confirm by
ticking the box that an application to vary the main track premises
licence has been submitted with this application:
18(a) Do you hold any other premises licences that have been issued by
this licensing authority? Yes/No [delete as appropriate]
18(b) If the answer to question 18(a) is yes, please provide full
details:
 
19. Please set out any other matters which you consider to be relevant
to your application:
 
Part 6 – Declarations and Checklist (Please tick)
I/ We confirm that, to the best of my/ our knowledge, the information
contained in this application is true. I/ We understand that it is an
offence under section 342 of the Gambling Act 2005 to give information
which is false or misleading in, or in relation to, this application.
Checklist:
*
Payment of the appropriate fee has been made/is enclosed
*
A plan of the premises or proposed premises is enclosed
*
I/ we understand that if the above requirements are not complied
with the application may be rejected
*
I/ we understand that it is now necessary to advertise the
application and give the appropriate notice to the responsible
authorities
Part 7 – Signatures
20. Signature of applicant or applicant’s solicitor or other duly
authorised agent. If signing on behalf of the applicant, please state
in what capacity:
Signature:
Print Name:
 
Date:
  (dd/mm/yyyy)
Capacity:
 
21. For joint applications, signature of 2nd applicant, or 2nd
applicant’s solicitor or other authorised agent. If signing on behalf
of the applicant, please state in what capacity:
Signature:
Print Name:
 
Date:
  (dd/mm/yyyy)
Capacity:
 
[Where there are more than two applicants, please use an additional
sheet clearly marked “Signature(s) of further applicant(s)”. The sheet
should include all the information requested in paragraphs 20 and 21.]
[Where the application is to be submitted in an electronic form, the
signature should be generated electronically and should be a copy of
the person’s written signature.].
Part 8 – Contact Details
22(a) Please give the name of a person who can be contacted about the
application:
 
22(b) Please give one or more telephone numbers at which the person
identified in question 22(a) can be contacted:
 
23. Postal address for correspondence associated with this
application:
 
Postcode: 
24. If you are happy for correspondence in relation to your
application to be sent via e-mail, please give the e-mail address to
which you would like correspondence to be sent: