Registration No: SL…………………….

KIRKLEES COUNCIL GAMBLING ACT 2005

NOTIFICATION OF CHANGE OF RESPONSIBLE PERSONS

Name of Society:	………………………………………………………………………………
Address of Society:	………………………………………………………………………………
………………………………….………………………….……	Post code: ………………...

Person responsible for promoting the lottery:

Full Name:		…………………………………………………………………………….
Full Address:		…………………………………………………………………………….
…………………………………………………………………………………………………….	
Post Code: ……………….. ……………………..		Tel No: …………………………… Position in Society: ……………………………………………………………………………..

Persons appointed to sign returns:

Full Name:		…………………………………………………………………………….
Full Address:		…………………………………………………………………………….
…………………………………………………………………………………………………….	
Post Code: ……………….. ……………………..		Tel No: …………………………… Position in Society: ……………………………………………………………………………..

Full Name:		…………………………………………………………………………….
Full Address:		…………………………………………………………………………….
…………………………………………………………………………………………………….	
Post Code: ……………….. ……………………..		Tel No: …………………………… Position in Society: ……………………………………………………………………………..

Personal Data
We have recently updated our Privacy Notice about how we use personal data provided to the Council. Further information can be found at:  http://www.kirklees.gov.uk/beta/information-and-data/pdf/privacy-notice-licensing-gambling-act.pdf