Change of name or address for the DPS on a Premises Licence Change of name/address for a Designated Premises Supervisor Fields marked with * are required I wish to notify the Licensing Team at Breckland Council of* change of name of the Designated Premises Supervisor (DPS) for a Premises Licence new address of the Designated Premises Supervisor (DPS) for a Premises Licence both Change of name DPS previous name DPS new full name Date effective from (DD/MM/YYYY) Reason for change Please upload proof of change of name (for example marriage certificate/deed poll certificate) Permitted file types: JPEG, PNG, PDF. Maximum file size: 5MB Change of address DPS Full name DPS previous address Postcode DPS new address Postcode DPS Telephone number Date effective from (DD/MM/YYYY) Return licence details Please return the premises licence to Licensing Team, Breckland Council, Elizabeth House, Walpole Loke, Dereham, NR19 1EE I will return the the original premises licence * Yes No If you will are not able to return the premises licence, please give reasons why not Next Page Last updated: 22/05/2023 13:41:30
