Licensing Team, Millmead House, Millmead, Guildford, Surrey, GU2 4BB

Applicationtovaryaclubpremisescertificatetobegranted

undertheLicensingAct2003

PLEASEREADTHEFOLLOWINGINSTRUCTIONSBEFORECOMPLETINGAPPLICATION

Beforecompletingthisformpleasereadtheguidancenotesattheendoftheform.

Ifyouarecompletingthisformbyhandpleasewritelegiblyinblockcapitals. Inallcasesensurethatyouranswersareinsidetheboxesandwritteninblackink. Useadditionalsheetsifnecessary.

Youmaywishtokeepacopyofthecompletedformforyourrecords.

(Insertnameofclub)

clubappliesforaclubpremisescertificateundersection84oftheLicensingAct2003forthepremisesnamedinPart1below

Club premises certificate number

Part1–Clubpremisesdetails

Nameofclub
Postaladdressofpremises,ifany,orifnoneordnancesurveymapreferenceordescription
Posttown / Postcode
Telephonenumber(ifany)
E-mailaddress(optional)
Nameofpersonperformingdutiesofasecretarytotheclub
Addressofpersonperformingdutiesofasecretarytotheclub
Posttown / Postcode
Daytimecontacttelephonenumber(ifany)
E-mailaddress(optional)

Part2–Applicantdetails

Daytimecontacttelephonenumber(ifany)
E-mailaddress(optional)
Currentpostaladdressifdifferentfrompremisesaddress
Posttown / Postcode

Part3-Variation

Pleasetick
Doyouwanttheproposedvariationtohaveeffectassoonaspossible? Yes No
DD / MM / YYYY
Ifnot,fromwhatdatedoyouwantthevariationtotakeeffect?

Do you want the proposed variation to have effect in relation to the introduction of the late night levy? (Please see guidance note 1) Yes No

Pleasedescribebrieflythenatureoftheproposedvariation(Pleaseseeguidancenote2)
Iftheclub’sproposedvariationwouldmeanthat5,000ormorepeopleareexpectedtoattendthepremisesatanyonetime,pleasestatethenumberexpectedtoattend /

Part4–ClubOperatingSchedule

PleasecompletethosepartsoftheClubOperatingSchedulewhichwouldbesubjecttochangeifthisapplicationtovaryissuccessful.

Whatqualifyingclubactivitiesdoyouintendtoconductontheclubpremiseswhichwillbeaffectedbyyourapplication?

Provisionofregulatedentertainment: / Pleasetickasappropriate
a) / plays(iftickingyes,fillinboxA)
b) / films(iftickingyes,fillinboxB)
c) / indoorsportingevents(iftickingyes,fillinboxC)
d) / boxingorwrestlingentertainments(iftickingyes,fillinboxD)
e) / livemusic(iftickingyes,fillinboxE)
f) / recordedmusic(iftickingyes,fillinboxF)
g) / performancesofdance(iftickingyes,fillinboxG)
h) / anythingofasimilardescriptiontothatfallingwithin(e),(f)or(g)(iftickingyes,fillinboxH)
Thesupplyofalcoholbyoronbehalfofaclubto,ortotheorderof,amemberoftheclub(iftickingyes,fillinboxI)
Thesalebyretailofalcoholbyoronbehalfofaclubtoaguestofamemberoftheclubforconsumptiononthepremiseswherethesaletakesplace(iftickingyes,fillinboxJ)

InallcasescompleteboxesK,LandM

Plays
Standarddaysandtimings(pleasereadguidancenote7) / Willtheperformanceofaplaytakeplaceindoorsoroutdoorsorboth–pleasetick(pleasereadguidancenote3) / Indoors
Outdoors
Day / Start / Finish / Both
Mon / Pleasegivefurtherdetailshere(pleasereadguidancenote4)
Tue
Wed / Stateanyseasonalvariationsforperformingplays(pleasereadguidancenote5)
Thur
Fri / Nonstandardtimings. Wheretheclubintendstousethepremisesfortheperformanceofaplayatdifferenttimesfromthoselistedinthecolumnontheleft,pleaselist(pleasereadguidancenote6)
Sat
Sun

Films
Standarddaysandtimings(pleasereadguidancenote7) / Willtheexhibitionoffilmstakeplaceindoorsoroutdoorsorboth–pleasetick(pleasereadguidancenote3) / Indoors
Outdoors
Day / Start / Finish / Both
Mon / Pleasegivefurtherdetailshere(pleasereadguidancenote4)
Tue
Wed / Stateanyseasonalvariationsfortheexhibitionoffilm(pleasereadguidancenote5)
Thur
Fri / Nonstandardtimings. Wheretheclubintendstousethepremisesfortheexhibitionoffilmatdifferenttimesfromthoselistedinthecolumnontheleft,pleaselist(pleasereadguidancenote6)
Sat
Sun

Indoorsportingevents
Standarddaysandtimings(pleasereadguidancenote7) / Pleasegivefurtherdetailshere(pleasereadguidancenote4)
Day / Start / Finish
Mon
Tue / Stateanyseasonalvariationsforindoorsportingevents(pleasereadguidancenote5)
Wed
Thur / Non-standardtimings. Wheretheclubintendstousethepremisesforindoorsportingeventsatdifferenttimesfromthoselistedinthecolumnontheleft,pleaselist(pleasereadguidancenote6)
Fri
Sat
Sun

Boxingorwrestlingentertainments
Standarddaysandtimings(pleasereadguidancenote7) / Willtheboxingorwrestlingentertainmenttakeplaceindoorsoroutdoorsorboth–pleasetick(pleasereadguidancenote3) / Indoors
Outdoors
Day / Start / Finish / Both
Mon / Pleasegivefurtherdetailshere(pleasereadguidancenote4)
Tue
Wed / Stateanyseasonalvariationsforboxingorwrestlingentertainment(pleasereadguidancenote5)
Thur
Fri / Non-standardtimings. Wheretheclubintendstousethepremisesfortheboxingorwrestlingentertainmentatdifferenttimesfromthoselistedinthecolumnontheleft,pleaselist(pleasereadguidancenote6)
Sat
Sun

Livemusic
Standarddaysandtimings(pleasereadguidancenote7) / Willtheperformanceoflivemusictakeplaceindoorsoroutdoorsorboth–pleasetick(pleasereadguidancenote3) / Indoors
Outdoors
Day / Start / Finish / Both
Mon / Pleasegivefurtherdetailshere(pleasereadguidancenote4)
Tue
Wed / Stateanyseasonalvariationsfortheperformanceoflivemusic(pleasereadguidancenote5)
Thur
Fri / Non-standardtimings. Wheretheclubintendstousethepremisesfortheperformanceoflivemusicatdifferenttimesfromthoselistedinthecolumnontheleft,pleaselist(pleasereadguidancenote6)
Sat
Sun

Recordedmusic
Standarddaysandtimings(pleasereadguidancenote7) / Willtheplayingofrecordedmusictakeplaceindoorsoroutdoorsorboth–pleasetick(pleasereadguidancenote3) / Indoors
Outdoors
Day / Start / Finish / Both
Mon / Pleasegivefurtherdetailshere(pleasereadguidancenote4)
Tue
Wed / Stateanyseasonalvariationsfortheplayingofrecordedmusic(pleasereadguidancenote5)
Thur
Fri / Non-standardtimings. Wheretheclubintendstousethepremisesfortheplayingofrecordedmusicatdifferenttimesfromthoselistedinthecolumnontheleft,pleaselist(pleasereadguidancenote6)
Sat
Sun

Performancesofdance
Standarddaysandtimings(pleasereadguidancenote7) / Willtheperformanceofdancetakeplaceindoorsoroutdoorsorboth–pleasetick(pleasereadguidancenote3) / Indoors
Outdoors
Day / Start / Finish / Both
Mon / Pleasegivefurtherdetailshere(pleasereadguidancenote4)
Tue
Wed / Stateanyseasonalvariationsfortheperformanceofdance(pleasereadguidancenote5)
Thur
Fri / Non-standardtimings. Wheretheclubintendstousethepremisesfortheperformanceofdanceatdifferenttimesfromthoselistedinthecolumnontheleft,pleaselist(pleasereadguidancenote6)
Sat
Sun

Anythingofasimilardescriptiontothatfallingwithin(e),(f)or(g)
Standarddaysandtimings(pleasereadguidancenote7) / Pleasegiveadescriptionofthetypeofentertainmentthattheclubwillbeproviding
Day / Start / Finish / Willthisentertainmenttakeplaceindoorsoroutdoorsorboth–pleasetick(pleasereadguidancenote3) / Indoors
Mon / Outdoors
Both
Tue / Pleasegivefurtherdetailshere(pleasereadguidancenote4)
Wed
Thur / Stateanyseasonalvariationsforthisentertainment(pleasereadguidancenote5)
Fri
Sat / Non-standardtimings. Wheretheclubintendstousethepremisesforthisentertainmentatdifferenttimesfromthoselistedinthecolumnontheleft,pleaselist(pleasereadguidancenote6)
Sun

Supplyofalcohol
Standarddaysandtimings(pleasereadguidancenote7) / Willthesupplyofalcoholbeforconsumption–pleasetick (pleasereadguidancenote8) / Onthepremises
Offthepremises
Day / Start / Finish / Both
Mon / Stateanyseasonalvariations(pleasereadguidancenote5)
Tue
Wed
Thur / Non-standardtimings. Wheretheclubintendstousethepremisesforthesupplyofalcoholatdifferenttimesfromthoselistedinthecolumnontheleft,pleaselist(pleasereadguidancenote6)
Fri
Sat
Sun

Hoursclubpremisesareopentothemembersandguests
Standarddaysandtimings(pleasereadguidancenote7) / Stateanyseasonalvariations(pleasereadguidancenote5)
Day / Start / Finish
Mon
Tue
Wed
Nonstandardtimings. Whereyouintendthepremisestobeopentothemembersandguestsatdifferenttimesfromthoselistedinthecolumnontheleft,pleaselist(pleasereadguidancenote6)
Thur
Fri
Sat
Sun

Pleasehighlightanyadultentertainmentorservices,activities,otherentertainmentormattersancillarytotheuseofthepremisesthatmaygiverisetoconcerninrespectofchildren(pleasereadguidancenote9).

Pleaseidentifythoseconditionscurrentlyimposedonthecertificatewhichyoubelievecouldberemovedasaconsequenceoftheproposedvariationyouareseeking.
Pleasetickasappropriate
/ Ihaveenclosedtheclubpremisescertificate
/ Ihaveenclosedtherelevantpartoftheclubpremisescertificate

Ifyouhavenottickedoneoftheseboxes,pleasefillinreasonsfornotincludingthecertificateorpartofitbelow

Reasonswhytheclubhasnotenclosedtheclubpremisescertificateorrelevantpartofit:

M – Describethestepsyouintendtotaketopromotethefourlicensingobjectives:

a)General–allfourlicensingobjectives(b,c,dande)(pleasereadguidancenote10)

b)Thepreventionofcrimeanddisorder

c)Publicsafety

d) The prevention of public nuisance

e) The protection of children from harm

Checklist:

Pleaseticktoindicateagreement
/ Ihavemadeorenclosedpaymentofthefee; or
I have not made or enclosed payment of the fee because this application has been made in relation to the introduction of the late night levy.
/ Ihavesentcopiesofthisapplicationandtheplantoresponsibleauthorities.
/ IunderstandthatImustnowadvertisemyapplication.
/ Ihaveenclosedtheclubpremisescertificateorrelevantpartofitorexplanation.
/ IunderstandthatifIdonotcomplywiththeaboverequirementsmyapplicationwillberejected.

ITISANOFFENCE,LIABLEONSUMMARYCONVICTIONTOAFINENOTEXCEEDINGLEVEL5ONTHESTANDARDSCALE,UNDERSECTION158OFTHELICENSINGACT2003,TOMAKEAFALSESTATEMENTINORINCONNECTIONWITHTHISAPPLICATION.

Part 5 – Signatures (please read guidance note 11)

(Insertfullname)

makethisapplicationonbehalfoftheclubandhaveauthoritytobindtheclub

Signature
Date
Capacity
Addressforcorrespondenceassociatedwiththisapplication(pleasereadguidancenote12)
Post town / Postcode
Telephone number (if any)
Ifyouwouldpreferustocorrespondwithyoubyemail,youremailaddress(optional)

NotesforGuidance

You do not have to pay a fee if the only purpose of the variation for which you are applying is to avoid becoming liable to the late night levy.
Describethepremises,Forexamplethetypeofpremisesitis,itsgeneralsituationandlayoutandanyotherinformationwhichwouldberelevanttothelicensingobjectives.Whereyourapplicationincludesoff-suppliesofalcoholandyouintendtoprovideaplaceforpeopletoconsumetheseoff-supplies,pleaseincludeadescriptionofwherethiswillbeanditsproximitytothepremises.
Wheretakingplaceinabuildingorotherstructurepleasetickasappropriate(indoorsmayincludeatent).
Pleasestatetypeofactivitytobeauthorised,ifnotalreadystated,andgiverelevantfurtherdetails,forexample(butnotexclusively)whetherornotmusicwillbeamplifiedorunamplified.
Forexample(butnotexclusively)wheretheactivitywillgoonforanextrahourduringsummermonths.
Forexample(butnotexclusively),whereyouwishtheactivitytogoonlongeronaparticulardaye.g.ChristmasEve.
Pleasegivetimingsin24hourclock(e.g.16:00).
Iftheclubwishesmembersandtheirgueststobeabletoconsumealcoholonthepremises,pleasetick‘onthepremises’.Iftheclubwishespeopletobeabletopurchasealcoholtoconsumeawayfromthepremises,pleasetick‘offthepremises’.Iftheclubwishespeopletobeabletodoboth,pleasetick‘both’.
Pleasegiveinformationaboutanythingtooccuratthepremisesorancillarytotheuseofthepremiseswhichmaygiverisetoconcerninrespectofchildren,forexample(butnotexclusively)nudityorsemi-nudity,filmsforrestrictedagegroupsorgamblingmachinesetc.
Pleaselistherestepsyouwilltaketopromoteallfourlicensingobjectivestogether.
Theapplicationformmustbesignedbysomeonewiththeauthoritytobindtheclub.
Thisistheaddresswhichwewillusetocorrespondwiththeclubaboutthisapplication.