| Section 22(2) |
| (To be completed in duplicate). |
| APPLICATION FOR TRANSFER OF LIQUOR LICENCE |
| (Under the provisions of section ........................................................... of the Liquor Licensing Act) |
| .................................... |
| (Date) |
| To: The Magistrate, |
| Licensing District No ............................. |
| 1. | Name of holder .............................................................................. |
| 2. | Address of holder ........................................................................... |
| 3. | Address of Licensed Premises .............................................................. |
| 4. | Number of Licensed Premises .............................................................. |
| 5. | Name of Transferee ......................................................................... |
| 6. | Address of Transferee ...................................................................... |
| 7. | Age of Transferee .......................................................................... |
| (State date and year of birth) |
| 8. | I ............................................ of ................ hereby agree to transfer the Licence No .................................... to .......................................... |
| ................................... |
| Signature of Transferer. |
| ................................... |
| Signature of Transferee. |
| 9. | Report of Commissioner of Police to be annexed. |