Licensing Act 2003
REPRESENTATION FORM FROM INTERESTED PARTIES

This representation is made by an Interested Party in the vicinity of the premises to be licensed as detailed below

Your name/organisation name/name of body you represent (see note 3)		
Organisation name/name of body you represent (if appropriate) (see note 3)		
Postal and email address

Contact telephone number		

Name of the premises you are making a representation about		
Address of the premises you are making a representation about.		

Your representation must relate to one of the four Licensing Objectives (see note 4)
Licensing Objective	Yes
Or No	Please detail the evidence supporting your representation or the reason for your representation.
Please use separate sheets if necessary	
To prevent crime and disorder

			
Public safety

			
To prevent public nuisance

			
To protect children from harm

			
Please suggest any conditions that could be added to the licence to remedy your representation or other suggestions you would like the Licensing Sub Committee to take into account. **		

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-licensing-gambling-act.pdf

NOTES

1.	If you do make a representation you will be expected to attend a meeting of the Licensing Authority’s Committee and any subsequent appeal proceeding.  If you do not attend, the Committee will consider any representations that you have made.

2.	This form must be returned within the statutory period of 28 days from the date the application was displayed on the premises of the date given in the public notice in a local newspaper or other local publication. 

3.	You must live, work or represent a body that is in the vicinity of the premises that you are writing about in order to make representations.

4.	These can only relate to the four licensing objectives.

5.	If you do make a representation you will be expected to attend a meeting of the Licensing Authority’s Committee and any subsequent appeal proceeding.  If you do not attend, the Committee will consider any representations that you have made.

6.	Your representation will be passed to the applicant, to allow them the opportunity of addressing your concerns.  Your representations will be published in the report available to the Licensing Committee, which will be publicly available.  Names and addresses will only be withheld from the Committee report at your request.  

7.	Please return this form when completed to:

Kirklees Council,
Licensing Department
Flint Street Depot
Flint Street
Fartown
Huddersfield
HD1 6LG
Tel: 	01484 456868
Email:	licensing@kirklees.gov.uk