Transfer an existing licence or permit - VCGLR
Transfer an existing licence or permit - VCGLR
Transfer an existing licence or permit - VCGLR
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Liqu<strong>or</strong> Licensing<br />
Questionnaire<br />
Liqu<strong>or</strong> Control Ref<strong>or</strong>m Act 1998<br />
The following inf<strong>or</strong>mation is required from each applic<strong>an</strong>t f<strong>or</strong> a liqu<strong>or</strong><br />
<strong>licence</strong> <strong>or</strong> <strong>permit</strong>. If the application is from a comp<strong>an</strong>y, partnership<br />
<strong>or</strong> club, a questionnaire is required from each direct<strong>or</strong>, partner <strong>or</strong><br />
executive committee member. If a nominee is to be appointed, then<br />
he <strong>or</strong> she is also required to provide the following inf<strong>or</strong>mation.<br />
Imp<strong>or</strong>t<strong>an</strong>t inf<strong>or</strong>mation you must read <strong>an</strong>d note<br />
bef<strong>or</strong>e completing this f<strong>or</strong>m<br />
The inf<strong>or</strong>mation supplied on this f<strong>or</strong>m to the Vict<strong>or</strong>i<strong>an</strong><br />
Commission f<strong>or</strong> Gambling <strong>an</strong>d Liqu<strong>or</strong> Regulation (the<br />
Commission) will be disclosed to Vict<strong>or</strong>ia Police as part of your<br />
application under the Liqu<strong>or</strong> Control Ref<strong>or</strong>m Act 1998 (the Act).<br />
Vict<strong>or</strong>ia Police will use the inf<strong>or</strong>mation you supply to make <strong>an</strong><br />
inf<strong>or</strong>med decision on whether to object to your application on the<br />
grounds that you <strong>or</strong> <strong>an</strong>yone named on this f<strong>or</strong>m are not suitable<br />
to be involved directly <strong>or</strong> indirectly in the sale of liqu<strong>or</strong>.<br />
Please Note:<br />
• Complete all sections of this f<strong>or</strong>m in BLOCK CAPITALS ONLY.<br />
• If you require <strong>an</strong>y help in completing this f<strong>or</strong>m, assist<strong>an</strong>ce<br />
c<strong>an</strong> be obtained from a legal practitioner <strong>or</strong> liqu<strong>or</strong> consult<strong>an</strong>t.<br />
• Failure to provide requested inf<strong>or</strong>mation (no matter<br />
how min<strong>or</strong>) may be detrimental to the outcome of your<br />
application.<br />
• Having a criminal rec<strong>or</strong>d in itself may not prevent you <strong>or</strong> a<br />
body c<strong>or</strong>p<strong>or</strong>ate you are involved with from being successful<br />
with your application.<br />
• It is a criminal offence under Section 118 of the Act to<br />
provide false <strong>or</strong> misleading statements.<br />
Personal inf<strong>or</strong>mation<br />
Family name<br />
First given name<br />
Second given name<br />
Date of birth<br />
Residential address<br />
Flat/unit number Street number<br />
Street name<br />
Town/suburb<br />
Postcode<br />
State<br />
Male<br />
Vict<strong>or</strong>i<strong>an</strong> Commission f<strong>or</strong> Gambling <strong>an</strong>d Liqu<strong>or</strong> Regulation<br />
49 Elizabeth Street, Richmond VIC 3121<br />
(Hours: 8:30 - 5:00) Monday to Friday – closed on public holidays<br />
GPO Box 1988, Melbourne VIC 3001<br />
Female<br />
Lot number<br />
Contact details<br />
Home phone (incl. area code)<br />
Mobile phone<br />
Business phone (incl. area code)<br />
Fax number (incl. area code)<br />
Driver <strong>licence</strong> number<br />
State of issue<br />
OFFICE USE ONLY 02/12<br />
Date Rec’d / /<br />
File No. ______________________<br />
Business address<br />
Flat/unit number Street number Lot number<br />
Street name<br />
Town/suburb<br />
Postcode<br />
Business details<br />
Name of business<br />
State<br />
Details of <strong>an</strong>y other person who will, <strong>or</strong> is likely, to <strong>or</strong> is likely to<br />
directly <strong>or</strong> indirectly have a m<strong>an</strong>agement role <strong>or</strong> exercise control<br />
over the business.<br />
Family name<br />
First given name<br />
Date of birth<br />
Telephone 1300 182 457<br />
www.vcglr.vic.gov.au<br />
DX 210976<br />
ABN 56 832 742 797<br />
Email address (please indicate c<strong>or</strong>rect case)<br />
Male<br />
Female<br />
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