Forms home Licensing Act 2003 Representation form Before completing this form please read the guidance notes at the end of the form. If you wish to make a representation either for or against an application for a Premises Licence or Club Premises Certificate please complete this form. Your personal detailsName(Required) First Last Address(Required) Street Address Address Line 2 City Post code Email(Required) PhoneDetails of the premises you are making a representationName of licenseeApplication reference numberName of premises(Required)Address of the premises(Required)Your representation must relate to one of the four Licensing Objectives (see note 3)Please detail the evidence supporting your representation or the reason for your representation in the appropriate box. (Please upload separate files if necessary)File Drop files here or The prevention of crime and disorderPublic safetyThe prevention of public nuisanceThe protection of children from harmDigital signature(Required)Please provide your full name as your digital signatureGUIDANCE NOTES ON COMPLETING THIS FORM 1. If you do make a representation you will be expected to attend a hearing of the Licensing Authority’s Committee and any subsequent appeal proceeding. If you do not attend, the Committee will consider your representations that you have made but may give them a lesser weight than if you attend. 2. This form must be returned within the statutory period displayed on the public notice. This date is shown on the premises notice, the public notice in a local newspaper or other local publication including the Licensing Authority’s web page. 3. Representations must relate to at least one of the four licensing objectives shown on the form. Whilst evidence can include what has happened or is currently happening they must refer to the expected impact if the application were to be granted. 4. Representation must not be considered by the Licensing Authority to be frivolous or vexatious 5. Your representation will be passed to the applicant, to allow them the opportunity to address your concerns. It will also be contained in the Agenda for the hearing which is a publicly available document. 6. In the first instance the council will only disclose your name and postcode with the representation. 7. If the applicant requests your full address the law expects the council to provide this too unless there are good reasons for not doing so. 8. In exceptional cases you can request the Licensing Authority to withhold your address. In any event the original representation must contain this information for it to be considered valid. 9. You must tell the council when you make your representation if you do not consent to your personal address being divulged to the applicant if requested. However, withholding such details will only be considered where the circumstances justify such action.