Gambling Act 2005 – Please return with annual fee 

Name of Society:		
Licensing Authority issued Registration number of Society:	              SL	

Name of Promoter on behalf of society

Name:

Address (including postcode):

Daytime telephone number:

Signed:						

Dated:
	
Declaration and Signatures 

We the undersigned, being two members of the Society who are appointed in writing by the Society, or its governing body, are authorised to countersign any returns provided on behalf of the Society in accordance with the provisions of Schedule 11, Part 4, Paragraph 39 of the Gambling Act 2005.	
Name:

Address (including postcode):

Signed:						

Dated: 	

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Name:

Address (including postcode):

Signed:	

Dated:

PLEASE NOTE THAT IT IS AN OFFENCE UNDER SECTION 342 OF THE GAMBLING ACT 2005, TO GIVE ANY FALSE OR MISLEADING INFORMATION WITHIN THIS RETURN.  

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