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Application For An Entertainment Venue Licence

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					                                                                                       Application For
                                                                      An Entertainment Venue Licence

      For assistance with this application, refer to ‘Entertainment Licence - Lodgement Guide’ and ‘Fees and
                                                         Charges’

1.       Type of applicant(s)                  Individual                Partnership                  Company/Companies
         (tick one or more boxes)


2.       Name of applicant(s)



3.       ABN/ACN Number



4.       Is the applicant acting as            Yes (Go to question 5)                        No (Go to question 7)
         a trustee for any trusts?


5.       Type of trust                         Unit trust                                    Family trust
         (tick one box)


6.       Name of the trust involved



7.       Contact details for
         enquiries                      Name:


                                        Phone:                                      Mobile:


                                        Fax:                                        Email:


8.       Proposed business
         (trading) name


9.       Address of premises or
         proposed premises              No:                 Street:


                                        Suburb/Town:                                                  Postcode:


                                        Daytime Phone No:                           Fax:


10.      Postal address (where
         information will be sent) If   No:                 Street:
         this is the same as the
         address of premises            Suburb/Town:                                                  Postcode:
         please write ‘as above’



                                                                                                    Office use only

                                                                                    Date………………………………………

                                        Please continue overleaf                    Receipt number….…………………….
                                                                                    Amount…………………………...……..
                                                                                    Initials…………………………………….

     t reviewed: June 2006:                                                 Level 9, East Wing, 50 Grenfell Street Adelaide SA 5000
     1 of 4                                                                                        GPO Box 2169 Adelaide SA 5001
                                                                                          Phone: (08) 8226 8410 Fax: (08) 8226 8512
                                                                         Email: olgc@agd.sa.gov.au Web Site: www.olgc.sa.gov.au
                                                                             Application For
                                                            An Entertainment Venue Licence

11.
      Plans                       Two plans of the premises must accompany this application:
                                          1) a black and white plan
                                          2) a plan with relevant colour code outlining designated areas.
                                             (refer ‘Submitting Plan - Lodgement Guide)


12.   Designated dining area           No                              Yes (please outline on one submitted plan)
      required?

13.   Supply of liquor without         No                              Yes
      a meal required?
      (section 35 (1) (c)

14.   Extended trading                 No                              Yes (Please complete the Application for
      authorisation required?                                                extended trading authorization form)

15.   Extension of trading             No                              Yes (Please complete the Application for
      area required?                                                         extension of trading area/ redefinition/
                                                                             alteration (liquor) form)


16.   On Appendix A, please list the persons requiring approval in any of the following categories:

                                  •   Director                     •    Adult Trust Beneficiary

                                  •   Shareholder                  •    Responsible Person

                                  •   Licensee

      For assistance refer to ‘Licensees, Directors and Shareholders Liquor Licensing Act, 1997 - Lodgement Guide’
      (Please photocopy if there is not enough space)




                                               Please continue overleaf




  t reviewed: June 2006:                                             Level 9, East Wing, 50 Grenfell Street Adelaide SA 5000
  2 of 4                                                                                    GPO Box 2169 Adelaide SA 5001
                                                                                   Phone: (08) 8226 8410 Fax: (08) 8226 8512
                                                                  Email: olgc@agd.sa.gov.au Web Site: www.olgc.sa.gov.au
                                                                                                   APPENDIX A
                                                                  APPLICATION FOR AN ENTERTAINMENT LICENCE

(a)   Surname

      Given Names




      Date of Birth                    ______/______/______            Female          Male

      Category of approval
      (tick one or more boxes)             Director                    Adult Trust Beneficiary

                                           Shareholder                 Responsible Person

                                           Licensee

      Has this person been
      previously approved?                 Yes                         No    (Please complete a Personal Information
                                                                                Declaration form)

      If yes, provide ID number and
      name of premises

      Is this person still currently
      approved?                            Yes                         No (Please complete an Application for
                                                                              approval of a person form)



(b)   Surname

      Given Names




      Date of Birth                        ______/______/______        Female          Male


      Category of approval
      (tick one or more boxes)             Director                    Adult Trust Beneficiary

                                           Shareholder                 Responsible Person

                                           Licensee

      Has this person been
      previously approved?                 Yes                         No (Please complete a Personal Information
                                                                              Declaration form)

      If yes, provide ID number and
      name of premises

      Is this person still currently
      approved?                            Yes                         No (Please complete an Application for
                                                                              approval of a person form)


                                                                                                  Please continue overleaf



  t reviewed: June 2006:                                             Level 9, East Wing, 50 Grenfell Street Adelaide SA 5000
  3 of 4                                                                                    GPO Box 2169 Adelaide SA 5001
                                                                                   Phone: (08) 8226 8410 Fax: (08) 8226 8512
                                                                  Email: olgc@agd.sa.gov.au Web Site: www.olgc.sa.gov.au
                                                                                                                                                                APPENDIX A
                                                                                                                   APPLICATION FOR AN ENTERTAINMENT LICENCE


(C)      Surname

         Given Names




         Date of Birth                                            ______/______/______                                  Female                Male

         Category of approval
         (tick one or more boxes)                                        Director                                       Adult Trust Beneficiary

                                                                          Shareholder                                   Responsible Person

                                                                         Licensee

         Has this person been
         previously approved?                                            Yes                                            No    (Please complete a Personal Information
                                                                                                                                 Declaration form)

         If yes, provide ID number and
         name of premises

         Is this person still currently
         approved?                                                       Yes                                            No (Please complete an Application for
                                                                                                                               approval of a person form)

(d)      Surname

         Given Names




         Date of Birth                                                   ______/______/______                           Female                Male


         Category of approval
         (tick one or more boxes)                                         Director                                      Adult Trust Beneficiary

                                                                         Shareholder                                    Responsible Person

                                                                          Licensee

         Has this person been
         previously approved?                                            Yes                                            No (Please complete a Personal Information
                                                                                                                            Declaration form)

         If yes, provide ID number and
         name of premises

         Is this person still currently
         approved?                                                       Yes                                            No (Please complete an Application for
                                                                                                                            approval of a person form)


  Applicant’s Signature: ...........................................................................................................................................................................


  Date: ........................................................................................................

  t reviewed: June 2006:                                                                                              Level 9, East Wing, 50 Grenfell Street Adelaide SA 5000
  4 of 4                                                                                                                                     GPO Box 2169 Adelaide SA 5001
                                                                                                                                    Phone: (08) 8226 8410 Fax: (08) 8226 8512
                                                                                                                   Email: olgc@agd.sa.gov.au Web Site: www.olgc.sa.gov.au

				
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Description: Application For An Entertainment Venue Licence