I :	
(full name of prospective premises supervisor)

Of:	

(home address of prospective premises supervisor)

Hereby confirm that I give m consent to being specified as the designated premises supervisor in 

relation to the application for _____________________________(type of application)

by	
(name of applicant)

Relating to a premises licence _________________________________________________________
(name of existing licence, if any)

for	

(name and address of premises to which the application relates)

and any premises licence to be granted or varied in respect of this application made by

(insert name of applicant]

concerning the supply of alcohol at 
	
[name and address of premises to which the application relates].

 I also confirm that I am applying for, intend to apply for or currently hold a personal licence, details of which I set out below.

Personal Licence number __________________________________(insert personal licence number, if any)

Personal Licence issuing authority    ___________________________________________________

Part A – Consent of individual to being specified as premises supervisor
    ___________________________________________________________________________________
 [insert name and address and telephone number of personal licence issuing authority, if any)

Signed ______________________________________________________________________________

Name (please print) ____________________________________________________________________

Date ________________________________________________________________________________
 
http://www.kirklees.gov.uk/beta/information-and-data/pdf/privacy-notice-licensing-gambling-act.pdf