KIRKLEES COUNCIL
HOUSE TO HOUSE COLLECTION ACT 1939
APPLICATION FOR LICENCE

TO:	Kirklees Council, Licensing Department, Flint Street Depot, Flint Street, Fartown, Huddersfield, HD1 6LG  Tel:  01484 456868  

PLEASE COMPLETE THIS FORM IN CAPITAL LETTERS

1	Full name of Applicant:	Mr/Mrs/Miss ……………………………………………….
2	Full address of Applicant:..	..…………………………………………………………….
	………………………………………………………………………………………………
	Post Code:..……………………Tel No: ……………………… DOB: ………..………
3	Particulars of charitable purposes to which proceeds of collection are to be applied. (Full details should be given and, where possible, the most recent account of any charity which is to benefit should be enclosed):
………………………………………………………………………………………………
	………………………………………………………………………………………………
4	In which areas of Kirklees do you intend to make the collection?:
………………………………………………………………………………………………
5	When do you intend to hold the collection?: 
From: …………………............................ To: ………………………………………….
6	Do you intend to collect money?	                   Yes/No
7	Do you intend to collect other property?	        Yes/No
If so, of what nature, and is it proposed to sell such property, or give it away or use it? ……………………………………………………………………………………..
8	How many collectors are you intending to authorise?: ………………………………

9	Is it proposed that remuneration should be paid out of the proceeds of the collection to :- 

	(a) The collectors    Yes/No			(b) Other Persons   Yes/No

	If so, at what rates, and to what classes of persons?: ……………………………… 

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

10	Is application being made for Licences for collectors for the same purpose in other areas?  If so, to what authorities? : .……………………………………………..

11	Has the applicant, or anyone associated with the promotion of the collection been refused a Licence or Order under the Act, or had a Licence or Order revoked? Yes/No
	If so give full details: ……………………………………………………………………..
	………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
IMPORTANT NOTE 

PLEASE SEE KIRKLEES HOUSE TO HOUSE COLLECTIONS POLICY FOR
DETAILS OF OTHER INFORMATION REQUIRED TO BE SUBMITTED WITH THIS FORM. A FAILURE TO SUBMIT ALL REQUIRED INFORMATION WILL MEAN THE APPLICATION IS REJECTED.

IN PURSUANCE OF Section 2 of the House to House Collection Act 1939, I hereby
Apply for a Licence authorising me to promote the collection of which particulars are
given above. I have also enclosed the extra information as required by the Councils House to House Collections Policy.

Signed: …………………………………………………………………………………………….

Date: ……………………………………………………………………………………………….

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