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Transfer an existing licence or permit - VCGLR

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Details of who is taking over the <strong>licence</strong> <strong>or</strong> <strong>permit</strong> (the tr<strong>an</strong>sferee)<br />

Name of proposed licensee <strong>or</strong> <strong>permit</strong> holder (person/partnership/comp<strong>an</strong>y/club) ACN (if applicable)<br />

If the trading name used at the premises will ch<strong>an</strong>ge, specify the new name here<br />

Give details of each individual, each partner, each direct<strong>or</strong>, comp<strong>an</strong>y secretary, public officer, executive committee member<br />

(if m<strong>or</strong>e th<strong>an</strong> 4 people, attach a separate page which lists all names <strong>an</strong>d addresses)<br />

Full name Residential address<br />

Associates (of the tr<strong>an</strong>sferee)<br />

An application f<strong>or</strong> tr<strong>an</strong>sfer must provide the names, dates of birth <strong>an</strong>d addresses of the tr<strong>an</strong>sferee's associates. If the proposed tr<strong>an</strong>sferee is<br />

a body c<strong>or</strong>p<strong>or</strong>ate, this should include associates of the direct<strong>or</strong>s. Bef<strong>or</strong>e completing this application f<strong>or</strong> a liqu<strong>or</strong> <strong>licence</strong>, ensure that you read<br />

<strong>an</strong>d underst<strong>an</strong>d the expl<strong>an</strong>ation of what is me<strong>an</strong>t by ‘associate’ on the last page of this f<strong>or</strong>m.<br />

The tr<strong>an</strong>sferee has no associates as defined in the Liqu<strong>or</strong> Control Ref<strong>or</strong>m Act 1998 (tick if applicable) OR<br />

The names of all the tr<strong>an</strong>sferee's associates are:<br />

Provide details of all associates (attach <strong>an</strong>other sheet if necessary)<br />

Full name of associates Residential address Date of birth<br />

Signature of tr<strong>an</strong>sferee<br />

Who must sign this application – If the licensee/<strong>permit</strong> holder is:<br />

An individual The individual person - A comp<strong>an</strong>y One direct<strong>or</strong> of the comp<strong>an</strong>y - A partnership All partners - A club One committe<br />

member<br />

Certification – I/We apply to tr<strong>an</strong>sfer the <strong>licence</strong> as outlined in this application <strong>an</strong>d certify that:<br />

• upon tr<strong>an</strong>sfer, I/we will be the freehold owner/s of the premises <strong>or</strong> will have exclusive right to occupy the premises; <strong>an</strong>d<br />

• the <strong>existing</strong> approved pl<strong>an</strong> of the licensed premises held by the Vict<strong>or</strong>i<strong>an</strong> Commission f<strong>or</strong> Gambling <strong>an</strong>d Liqu<strong>or</strong> Regulation accurately<br />

depicts the flo<strong>or</strong> layout of the premises. (Note: If the pl<strong>an</strong> does not accurately depict the layout of the premises, you must submit a new<br />

pl<strong>an</strong> with this application).<br />

Name<br />

Date<br />

/ /<br />

Name<br />

Postcode<br />

Postcode<br />

Postcode<br />

Postcode<br />

Date<br />

/ /<br />

TRANS-02/12 2 of 4

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