NAME:................................................................................................................................................

COMPANY:........................................................................................................................................

ADDRESS:..........................................................................................................................................

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PHONE:............................................................FAX:.........................................................................

EMAIL:...............................................................................................................................................

PREMISES

NAME:...............................................................................................................................................

ADDRESS:.........................................................................................................................................

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PHONE:..............................................................................................................................................

I would like Young & Smith to make the following applications:
Personal Licence....................................................................Yes / No.
Premises Licence...................................................................Yes / No.
Designated Premises Supervisor..........................................Yes / No.

Comments:
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You authorise Young & Smith to act as your agent in applying for any relevant authority that Young & Smith consider you may require under the terms of the Licensing Act 2003.in doing so,Young & Smith may need to complete documents,forms and applications on your behalf which will be forwarded to the relevant authorities to further your application.Young & Smith will rely on the information supplied by you ,your company representatives, your staff or your licensees,and will accept no responsibility for loss howsoever caused as a result of any error,omission or representation contained in any documents,forms or applications completed on your behalf.

Signed:............................................................................................................Dated:............................................................................