| (Sections 6(1), 7(2), 11(a), and 12) |
APPLICATION FOR A CERTIFICATE FOR A
LICENCE TO SELL INTOXICATING LIQUOR |
(Under the provisions of section .......................... of the
Liquor Licensing Act) |
| ...................................... |
| (Date) |
| To: The Clerk, |
| Licensing District No ............ |
| I ........................................ of ...................................................... |
| (name) | (address) |
| hereby make application for a .............................................................. licence |
| (type of licence) |
| in respect of premises situate at .................................................................... |
| (address of proposed premises) |
| 2. | I am over 21 years of age. |
| 3. | (1) | I hold a ....................................... licence at present in respect of premises situate ................................................................ |
| (2) | I do not hold a licence at present. |
| (Answer (1) or (2) above). |
| 4. | Particulars of proposed premises. |
| (1) | Do these premises occupy an entire building? | ....................................... |
| (Answer “Yes” or “No”) |
| (2) | If “No”, what is the rest of the building used for? | ....................................... |
| (3) | Do you live “In” or “Near” the premises? | ....................................... |
| (Answer “In” or “Near”) |
| (4) | If “Near”, how far? | ....................................... |
| (5) | Number of rooms contained in the premises? | ....................................... |
| (6) | Number of doors? | ....................................... |
| (7) | Number of windows? | ....................................... |
| (8) | Number of other licensed premises in your village street or road? | ....................................... |
| (9) | Or alternatively— |
| Number of other licensed premises within the radius of a mile? | ....................................... |
| (10) | Or average number of persons residing within the radius of a mile? | ....................................... |
| (11) | Or average number of dwelling within the radius of a mile? | ....................................... |
| 5. | (1) | Have you applied for a certificate before? | ....................................... |
| (Answer “Yes” or “No”) |
| (2) | What was the result? | ....................................... |
| (Answer “Granted” or “Refused”) |
| (3) | If “Refused” state why | ....................................... |
| ....................................... |
| (Signature of Applicant). |