Notification of Interest application form

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Notification of an interest in premises under section 178 of the Licensing Act 2003
Fields marked with * are required
Before completing this form please read the guidance notes
Notifier declaration
1. I/We hereby give/gives notice of my/our interest in the premises identified below for the purposes of section 178 of the Licensing Act 2003*
  Please provide full name(s) of notifier
Part 1 – Premises details
1. Postal address of premises or, if none, Ordnance Survey map reference or description*
2. Address line 2
3. Post town*
4. Postcode*
5. Name of applicant for, or holder of, premises licence or club applying for, or holding, club premises certificate (if known)
6. Premises licence/Club Premises Certificate number (if known)

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