Application for a Special Circumstances Licence - Consumer and ...

Special Circumstances Licence ApplicationOffice use onlyDate --------------------------------------------Receipt No ------------------------------------Amount --------------------------------- Initials ---------------------Customer Service CentreVisit us: 91 Grenfell Street, ADELAIDE SA 5000Mail to: GPO Box 2169, ADELAIDE SA 5001Ph: 08 8226 8655Email: applications@agd.sa.gov.auWeb: www.cbs.sa.gov.auFor assistance with this application, please contact the Customer Service Centre1. Type of applicant(s)(tick one or more boxes) Individual Partnership Company/Companies2. Name of applicant(s)3. ABN/ACN Number4. Is the applicant acting asa trustee for any trusts? Yes (go to question 5) No (go to question 7)5. Type of trust(tick one box) Unit trust Family trust6. Name of the trust involved7. Contact details forenquiriesName:Phone:Mobile:Fax:Email:8. Proposed business(trading) name9. Address of premises orproposed premises No: Street:Suburb/Town:Postcode:Daytime Phone No:Fax:1 of 5

Part B cont. – Licensed Premise Details9. Proposed Premises DetailsStreet Number.StreetSuburb/TownPostcodeDaytime telephone numberMobileFaxEmailPart C – Additional Information10. Plans Two plans of the premises must accompany this application:1) a black and white plan2) a plan with relevant colour code outlining designated areas.(refer ‘Submitting Plan - Lodgement Guide)11. Extended TradingAuthorisation Required?(trade between either 8amto 11am AND/OR midnightand 2am)12. Entertainment ConsentRequired?(between either 8am to11am AND/OR midnight and2am)13. Extension of Trading AreaRequired? (Has an OutdoorDining Permit been Approved bythe relevant Local Council) No Yes (please complete the Applicationfor Extended Trading AuthorisationConsent) No Yes (please complete the Applicationfor Entertainment Consent) No Yes (Please submit copy of Local CouncilPermit)14. On Appendix A, please listthe persons requiringapproval in any of thefollowing categories:LicenseeDirectorShareholderAdult Trust BeneficiaryResponsible PersonPart D – Applicant’s SignatureApplicant SignatureDate / /Print NamePosition/TitleSmall Venue Licence Application Updated: April 2013 2 of 6

Special Circumstances Licence Application22. Details of condition(s)sought(Attach separate sheet ifnecessary)23. On Appendix A, please list the persons requiring approval in any of the following categories:DirectorShareholderAdult Trust BeneficiaryResponsible PersonLicenseeFor assistance refer to ‘Licensees, Directors and Shareholders Liquor Licensing Act, 1997 - Lodgement Guide’(Please photocopy if there is not enough space)3 of 5

Appendix ASpecial Circumstances Licence Application(a)SurnameGiven NamesDate of Birth ______/______/______ Female MaleCategory of approval(tick one or more boxes) Director Shareholder Licensee Adult Trust Beneficiary Responsible PersonHas this person beenpreviously approved? Yes No Please complete a Personal InformationDeclaration form)If yes, provide ID number andname of premisesIs this person still currentlyapproved? Yes No Please complete an Application forapproval of a person form)(b)SurnameGiven NamesDate of Birth ______/______/______ Female MaleCategory of approval(tick one or more boxes) Director Shareholder Licensee Adult Trust Beneficiary Responsible PersonHas this person beenpreviously approved? Yes No Please complete a Personal InformationDeclaration form)If yes, provide ID number andname of premisesIs this person still currentlyapproved? Yes No Please complete an Application forapproval of a person form)4 of 5