Apply for a Provisional Statement

Application for a provisional statement to be granted under the Licensing Act 2003
Fields marked with * are required
Before completing this form please read the guidance notes
Applicant declaration
1. I/We apply for a provisional statement under section 29 of the Licensing Act 2003 for the premises described in Part 1 below (the premises) and I/we are making this application to you as the relevant licensing authority in accordance with section 12 of the Licensing Act 2003*
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. Telephone number at premises (if any)
6. Non-domestic rateable value of premises*
  
  Premises under construction, fee payable is £315
  
  None to £4,300, fee payable is £100
  
  £4,301 and £33,000, fee payable is £190
  
  £33,001 and £87,000, fee payable is £315
  
  £87,001 and £125,000, fee payable is £450
  
  £125,001 or more, fee payable is £635

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