Notify of change of name /address for Premises Licence Holder

Change of name/address of a Premises Licence holder for a Premises Licence
Fields marked with * are required
I wish to notify the Licensing Team at Breckland Council of*
1. change of name of the Premises Licence Holder (PLH) for a Premises Licence, fee is £10.50
2. new address of the Premises Licence Holder (PLH) for a Premises Licence, Fee is £10.50
3. Both, fee is £10.50
Change of name
2. PLH previous name
3. PLH new full name
4. Date effective from (DD/MM/YYYY)
5. Reason for change
6. 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
2. PLH Full name
3. PLH previous address
4. PLH contact telephone number
5. Postcode
6. PLH new address
7. Postcode
8. PLH contact telephone number
9. Date effective from (DD/MM/YYYY)
Return licence details
1. Please return the premises licence to Licensing Team, Breckland Council, Elizabeth House, Walpole Loke, Dereham, NR19 1EE
2. I will return the the original premises licence *
  
  Yes
  
  No
3. If you are not able to return the premises licence, please give reasons why not

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