Application for a Special Circumstances Licence - Consumer and ...
Application for a Special Circumstances Licence - Consumer and ...
Application for a Special Circumstances Licence - Consumer and ...
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Appendix A<strong>Special</strong> <strong>Circumstances</strong> <strong>Licence</strong> <strong>Application</strong>(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 In<strong>for</strong>mationDeclaration <strong>for</strong>m)If yes, provide ID number <strong>and</strong>name of premisesIs this person still currentlyapproved? Yes No Please complete an <strong>Application</strong> <strong>for</strong>approval of a person <strong>for</strong>m)(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 In<strong>for</strong>mationDeclaration <strong>for</strong>m)If yes, provide ID number <strong>and</strong>name of premisesIs this person still currentlyapproved? Yes No Please complete an <strong>Application</strong> <strong>for</strong>approval of a person <strong>for</strong>m)4 of 5
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