Licensing Objectives
Declarations
Declaration Type* Sole Applicant - Individual or Other
Declarations
I have made or enclosed payment of the fee 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. I have sent copies of this application and the plan to responsible authorities and others where applicable. I understand I must now advertise my application. I understand I must now return the original premises licence, or relevant part of it or have provided an explanation why I will not be able to do this. I understand that if I do not comply with the above requirements my application will be rejected.
IT IS AN OFFENCE, UNDER SECTION 158 OF THE LICENSING ACT 2003, TO MAKE A FALSE STATEMENT IN OR IN CONNECTION WITH THIS APPLICATION. THOSE WHO MAKE A FALSE STATEMENT MAY BE LIABLE ON SUMMARY CONVICTION TO A FINE OF ANY AMOUNT
Signature/Declaration of applicant (the current premises licence holder) or applicant's solicitor or other duly authorised agent (see Guidance Note 13). If signing/applying on behalf of the applicant, please state your name and in what capacity you are
Signature/Declaration of applicant (the current premises licence holder) or applicant's solicitor or other duly authorised agent (see Guidance Note 13). If signing/applying on behalf of the applicant, please state your name and in what capacity you are authorised to sign/apply. When submitting an on-line application form the 'Declaration made' checkbox must be selected.
Carys Williams
Full Name *
09/10/2026
Date *
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