Licensing Department

Declaration for a club premises certificate to be granted Under the Licensing Act 2003

PLEASE READ THE FOLLOWING INSTRUCTIONS BEFORE COMPLETING DECLARATION

Before completing this form please read the guidance notes at the end of the form.
If you are completing this form by hand please write legibly in block capitals. In all cases ensure that your answers are inside the boxes and written in black ink. Use additional sheets if necessary.  You may wish to keep a copy for your records.

Club premises details

Name of Club
	
Postal address of premises or, if none, ordnance survey map reference or description

Post town
	Post code	
Telephone number (if any)

	E-mail address (optional)	

CLUB DECLARATION AS TO QUALIFYING CLUB STATUS

……………………………………………………………………………………………………………….(Insert name of club) club makes the following declarations

1.	Where the club to which this application relates is:
a registered society within the meaning of the Industrial and Provident Societies Act 1965;
	a registered society within the meaning of the Friendly Societies Act 1974; or
	a registered friendly society within the meaning of the Friendly Societies Act, the   
      club declares that the club satisfies:

Please tick √ yes

  Condition 1 in section 62(2) of the Licensing Act 2003		                                    □
  Please give relevant club rule number(s)

  Condition 2 in section 62(3) of the Licensing Act 2003		                                    □
  Please give relevant club rule number(s)

  Condition 4 in section 62(5) of the Licensing Act 2003		                                     □
  Please give relevant club rule number(s), 

 
  Does the club wish to supply alcohol to members and guests?		                        □
  If yes the club declares that – 

  The purchase of alcohol for the club and the supply of alcohol by the club	           □
  is under the control of the members or of a committee appointed by members

  Please give relevant club rule number(s), if any

2) Where the club to which this application relates is:
    an association organised for the social well-being and recreation of persons employed  
    in or about coal mines, the club declares that the club satisfies:
				
								Please tick √ yes

  Condition 1 in section 62(2) of the Licensing Act 2003		                                       □
  Please give relevant club rule number(s)

  Condition 2 in section 62(3) of the Licensing Act 2003		                                      □
  Please give relevant club rule number(s)

   Does the club wish to supply alcohol to members and guests?		                          □
   If yes the club declares that it satisfies – 

   First condition in section 66(4) of the Licensing Act 2003		                          □
   Please give relevant club rule number(s)

 Second condition in section 66(5) of the Licensing Act 2003		                           □
 Please give relevant club rule number(s)

3) Where the club to which this application relates does not fall into the categories in 1 or 2 above, the club declares that the club satisfies:
									Please tick √ yes

 Condition 1 in section 62(2) of the Licensing Act 2003			                    □
 Please give relevant club rule number(s)

		
						
 Condition 2 in section 62(4) of the Licensing Act 2003			                     □	
 Please give relevant club rule number(s)

      
 Condition 3 in section 62(4) of the Licensing Act 2003			                      □

 The club’s arrangements for restricting the club’s freedom of purchase of alcohol are:

(a)	contained in club rule number(s)

(b)	or, as follows
(please provide a short description)

	

The club’s provisions by which money or property of the club or any gain arising from the       carrying on of the club is or may be applied for charitable benevolent or political purposes are:

(c)	contained in club rule number(s)

(d)	or, as follows
(please provide a short description)

	

The arrangements for giving members information about the finances of the club are:

(e)	contained in club rule number(s)

(f)	or, as follows
(please provide a short description)

	

Please describe details of the books of account and other records kept to ensure the accuracy of the information about finances given to members of the club or give the relevant rule number(s)

	
	
							Please tick √ yes

Condition 4 in section 62(5) of the Licensing Act 2003			                          □

Condition 5 in section 62(6) of the Licensing Act 2003			                          □

The club proposes to supply alcohol to members and guests		                          □
and declares that the club satisfies:

additional condition 1 in section 64(2) of the Licensing Act 2003		                          □

Please give relevant club rule number(s), if any

additional condition 2 in section 64(3) of the Licensing Act 2003		                         □

Please give relevant club rule number(s), if any

additional condition 3 in section 64(4) of the Licensing Act 2003 		                         □

Please give relevant club rule number(s), if any

			
IT IS AN OFFENCE, LIABLE ON CONVICTION TO A FINE UP TO LEVEL 5 ON THE STANDARD SCALE, UNDER SECTION 158 OF THE LICENSING ACT 2003, TO MAKE A FALSE STATEMENT IN OR IN CONNECTION WITH THIS APPLICATION

I …………………………………………………………………………….. Make this declaration on behalf of the club and have authority to bind the club

Signature…………………………………………………………………………………………..

Date…………………………………………………………………………………………………

Capacity……………………………………………………………………………………………

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