DISTRIBUTION OF FREE PRINTED MATTER
APPLICATION FORM
KIRKLEES LICENSING DEPARTMENT

Name of Organisation
		
Company Number

Address

		
Contact Name
		
Telephone Number

Please provide the following information

How many badges would you like?

………………………………………..

For temporary badges (charged at £38 per day) please specify which dates you would like to distribute

………………………………………..
………………………………………..
………………………………………...

Have you, your organisation or anybody working on behalf of your organisation been convicted of an offence under paragraph 1 of the Schedule 3A to the Environment Protection Act 1990?

Yes/No (please delete)

If yes please provide more detail:

Have you, your organisation or anybody working on behalf of your organisation paid a fixed penalty notice for the distribution of free literature without consent in a designated area, within 5 years preceding the date of this application in any English Local Authority area

Yes/No (please delete)
If yes please provide more detail:

	

Name: …………………………….. 

Capacity or position in organisation: ……………………………………….  

Signature: ………………………

Date: …………………………….

Note: Kirklees Council need not give consent to any application where it considers that the proposed distribution would in all circumstances be likely to lead to defacement of the designated land and the licence fee will not be refunded if a consent is not granted

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-other-licenses.pdf