Regulation 2
No.
Petty Sessions District of County Court Division of
| Name of premises (if any) and full address | Full name and address of licence holder | Kind of premises* (eg Art. 5(1)(a)) *also record here if a note such as is mentioned in Art. 5(5)(a) applies | ||||
| Full name and address of owner of premises | Date of [grant*] [provisional grant*] and name of Court *delete if inapplicable | Complete this box when provisional grant finalised Date grant declared final and name of Court | ||||
| Particulars, including date made and Court, of any order under Arts. 8, 31, 43, 44, 48 and of any notice served under Art. 31(1)(ii) | Particulars, including date made and periods of order, of renewals (R), transfers(T), surrenders (S), protection orders (P) and any notice served under Art. 28(3) | Particulars of:— (i)any condition imposed under Arts. 7(12) or 43(2); (ii)any direction given, varied or cancelled under Arts. 7(10) or (13), or 15(5) or (6); (iii)any declaration made or cancelled under Art. 107(1) or (5) of the Betting, Gaming, Lotteries and Amusements (N.I.) Order 1985 | Particulars, including date, Court and period of:— (i)any suspension arising from an application made under Art. 72(1) and the result of any appeal; (ii)any conviction of an offence such as is mentioned in Art. 75(1) and of any consequent order made, including suspension and the result of any appeal | Particulars, including date, of any children’s certificate granted under Art. 59 and of any order relating to the time when any such certificate should cease to be operational. Details of any subsequent revocation or modification of the certificate or any order should also be included | Particulars of the confirmation, reversal or variation of any decision or determination of any other Court relating to the licence or the licensed premises | Signature of clerk of petty sessions and date entry made |