Your name/company name/name of body you represent

Postal address

Email address

Contact telephone number

Name of the premises you are making a representation about

Address of the premises you are making a representation about

Your representation must relate to one of the four Licensing Objectives, below. Please state yes or no.

The prevention of harm to children - Yes no

To prevent public nuisance - Yes no

To prevent crime and disorder - Yes no

Public safety - Yes no

Suggested conditions that could be added to the licence to remedy your representation or other suggestions

If you would like to attach a supporting document please do so here

N.B if you do make representation you will be expected to attend the Licensing Sub-Committee and any subsequent appeal proceedings.

This form must be submitted within the Statutory Period, 28 days from the day the notice was displayed on the premises or the date specified in the public notice in the newspaper.