Consent of individual to being specified as premises supervisor
Full name of prospective premises supervisor
Mr.
Mrs.
Ms
Prefix
First Name
Last Name
Home address of prospective premises supervisor
Street Address
Street Address Line 2
Town
County
Post Code
Email address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: 00000-000000.
Relating to the premises licence at
Name of business
Street Address
Town
County
Post Code
I also confirm that I am entitled to work in the United Kingdom and am applying for, intend to apply for or currently hold a personal licence, details of which I set out below. Personal licence number
*
Insert personal licence number
Personal licence issuing authority
*
Insert name and address and telephone number of personal licence issuing authority
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Privacy Statement
Details of Surrey Heath Borough Council’s Privacy Notice can be found
here
Submit
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