EH Licensing - Personal Licence

EH Licensing - Personal Licence
I hereby apply to Surrey Heath Borough Council for Registration under the Local Government (Miscellaneous Provisions) Act, 1982, as a Practitioner in:
Please select the licence type you are applying for:*
Value
Name of Applicant*

First NameLast Name
Address*

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Has the applicant been convicted of an offence under Section 15 of the Act?*

YesNo
Nature of Offence:*
Court and date of hearing:*
Penalty imposed:*

Details of qualification and date gained:
Please upload a copy of your certificate here:

Cancelof
Address at which the practice is to be carried out:*

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Declaration
I declare that the information given in this application is to my best knowledge and belief, correct, and understand that a false declaration could result in the registration applied for being revoked.*

Please tick to confirm
Date*

DayMonthYear
The Council will enter the details on its Register. A register of the name of the operator, the name of the business, the address and the type of business carried on at each premises will be open to inspection by the general public. Records of the other information provided will be held by the local authority within the principles of the Data Protection Act 1998 and also may be subject to the Freedom of Information Act 2000. Please see here for further help.
Privacy Statement

Details of Surrey Heath Borough Council’s Privacy Notice can be found here.
By clicking on the 'Submit' button, you will be re-directed to Surrey Heath Borough Council's online payment page to make the appropriate payment. Your Licence will not be issued unless payment is made at application.

If you submit your application to the wrong council, non-refundable charge of £25 may be applied.
Should be Empty:

Declaration