Notice of Change in Management for Licensed Premises

*- indicates required field.

Please complete a separate form for each notification.

Reason for notification: *

Adding a new certificated manager

Termination/Cancellation of manager

Name of licensed premises: *

Licence number: * HelpText

Contact name for business: *

Address of licensed premises: *

Contact number: *

Contact email address: *

Full name of manager: *

Certificate number: * HelpText

Notification effective from: *