Docstoc

Personal - notification of change of name or address

Document Sample
Personal - notification of change of name or address Powered By Docstoc
					Environment and Regulatory Services, Derby City Council Celtic House, Heritage Gate, Friary Street, Derby
DE1 1QX. Telephone 01332 641930

LICENSING ACT 2003 NOTIFICATION OF CHANGE OF NAME OR ADDRESS

 PERSONAL LICENCE REFERENCE NUMBER (Please complete) PA1055
 CHANGE OF NAME DETAILS

 Old name
 Mr     Mrs             Miss          Ms          Other title

 Surname                                                        First names



 New name
 Mr     Mrs             Miss          Ms          Other title

 Surname                                                        First names




 CHANGE OF ADDRESS DETAILS

 NAME (Please Print): ______________________________________________________

 Old address




 Telephone No:

 New address




 Telephone No:

 Signature:………………………………………………………………………….

 The fee is £10.50 and must be sent with this form. Cheques should be made payable to
 ‘Derby City Council’. You should return your completed form and fee to:
 The Licensing Clerk, Environment and Regulatory Services, Derby City Council,
 Celtic House, Heritage Gate, Friary Street, Derby, DE1 1QX

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:0
posted:12/28/2011
language:
pages:1