fs east liquor permit application by HC120912214420


									                                    DEPARTMENT OF JUSTICE                                                                                                          www.nt.gov.au
                         LICENSING REGULATION AND ALCOHOL STRATEGY – Liquor Permit Application for East Arnhem General Restricted Area
                                                              Yirrkala                       Gunyangara                         Nhulunbuy
 Applicant Details

 Full Name:                                                                                             Date of Birth:      /      / 19               Employer:

 Residential Address:                                                                                  Postal Address:
 (Address you are residing at in the region)                                                           (Your PO Box No OR Your usual place of residence if not a permanent resident of the region) eg QLD

                                                                Postcode                                                                                                 Postcode

 Phone Home/Mobile:                                                                            Email (optional) :
 Do you identify as:        Aboriginal     Torres Strait Islander  Both Aboriginal and Torres Strait Islander  Non-Indigenous  Overseas Visitor 

  Permanent                         Temporary - dates permit required:     /             /           to            /       /
 Alcohol Preference (please tick)     Full Strength               Mid Strength                        Low Strength                      Wine                              Pre-Mixed
 Declaration by Applicant                                            Information For Permit Applicant                                     against my name, either in the Northern Territory or elsewhere.
                                                                                                                                          Further, I hereby indemnify the Northern Territory of Australia, its
I agree that I have read and understood the attached conditions,    Holding a liquor permit enables you to purchase and/or bring          servants and agents, including all members of the NT Police
or have had the conditions explained to me and understand           liquor into the Restricted Area or obtain it from premises within     against all liabilities and against all actions, suits, proceedings,
them, and agree to abide by them.                                   the Restricted Area that are licensed to sell liquor for removal      claims, demands, costs and expenses whatsoever which may be
I understand that if I do not abide by the attached conditions,     and consumption away from the premises and consumed in                taken or made in respect of the release or use hereunder of any
then the NT Licensing Commission may revoke or amend the            the prescribed/restricted area but not in quantities greater          details of any convictions or other information purporting to
permit, and that the NT Licensing Commission reserves the right     than, and not of types difference from those that are specified in    either relate to or involve me.
to place conditions as it deems fit.                                the permit.
                                                                                                                                           NT Licensing Commission
I also understand that I may appeal a decision about the refusal,    Privacy Statement
revocation or amendment of the permit by making a request in        I acknowledge that the information in this Permit Application and      DELEGATE OF THE NT LICENSING COMMISSION
writing to the NT Licensing Commission seeking a review within
28 days of receiving that notice.
                                                                    any information regarding liquor purchases made in accordance           APPROVED                               NOT APPROVED
                                                                    with the permit may be provided to Northern Territory Police and       Permit #
Signature of Applicant                     Date                     Licensing Inspectors of Licensing, Regulation & Alcohol Strategy
                                                                    for the purposes of enforcement and compliance with the Liquor         Name
                                                  /        /        Act. I understand that I have the right to inspect any and all
                                                                    information so compiled.
                                           Date                     I hereby consent to a check of the records of the Northern             Signature                                 Date
Signature of Witness (DoJ Officer)                                  Territory Police and release of details of any convictions, or
                                                                    other information, including, pursuant to section 15 of the                                                             /        /
                                                  /    /            Criminal Records (Spent Convictions) Act 1992, recorded
                    Terms and Conditions for ALL Liquor Permit Holders

       1. Applicants must have attained the age of 18 years and be a resident of East
          Arnhem Restricted Areas.

       2. All liquor purchased in accordance with the permit is to be obtained at licensed
          premises by the permit holder ONLY and by no other person.

       3. The Permit holder may only possess or consume liquor at their home residence or
          the residence of other permit holders within the East Arnhem General Restricted
          Area or those areas defined as exempt areas within East Arnhem Land.

       4. A permit may be revoked by the Licensing Commission at its discretion.
          A permit may also be revoked upon application to the Licensing Commission with a
          recommendation from the Liquor Permits Committee or a member of the Northern
          Territory Police, if the permit holder does one or more of the following:
          a)    causes substantial annoyance or disrupts community order and peace.
                 This may include: consuming liquor within the General Restricted Area, noisy parties,
                 public drunkenness, minor alcohol related disturbances, humbugging or begging; or
           b)    serious health conditions directly related to excessive alcohol consumption - i.e.:
                 renal problems
           c)    spending children’s money on liquor; or
           d)    supplies liquor to another person who is not a permit holder or who is not an invited
                 guest of the permit holder; or
           e)    is banned from any of the licensed premises within the East Arnhem District; or
           f)    it is believed that the safety of the person, their family or any member of the
                 community is being jeopardized by their drinking habits; or
           g)    assaults any person or is involved in alcohol-related domestic or family violence; or
           h)    illegally brings liquor into, or possesses liquor within a restricted area; or
           i)    brings a dangerous drug (defined in the Misuse of Drugs Act) into a restricted area;
           j)    possesses a dangerous drug within a restricted area; or
           k)    supplies a dangerous drug to another person; or
           l)    commits a drink driving traffic offence that results in an immediate suspension of
                 their drivers licence; or
           m)    The supplying of alcohol to any non permit holder less than 18 years of age, where
                 alcohol is consumed not under the effective control or supervision of a parent or
                 guardian; or
           n)    Restraining Order; or
           o)    Police order due to serious offences such as assault, burglary; or
           p)    At the discretion of the Court

       5. A person who has had their permit revoked may apply to have their permit reinstated by
       either completing an application form or applying to the Licensing Commission.

December 2011

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