Sex Establishment Licence Application

Application For Grant/Renewal/Transfer of a Sex Establishment Licence

Title:

Forename(s):

Surname:

Previous Surname (iff applicable):

Email:

 
Date of Birth:

National Insurance No:

 
Home Address:

Post Code:

Telephone No:

Mobile telephone no:

Previous Home Address (within last five years):

Post Code:

Licence Type:
Cost (£):

To be completed if the Application is made by a body corporate or an unincorporated body

Full name of the body:

Address of registered or principal office:

Post Code:

Telephone no:

Full names and private addresses of the directors or other persons responsible for its management

Name:

Address:

Post Code:

 
Name:

Address:

Post Code:

 
Name:

Address:

Post Code:

To be completed where the Application relates to premises

Full Address of premises:

Post Code:


To be completed where the Application relates to a vehicle, vessel or stall

Description of receptacle to be used (vehicle, vessel, trailer, stall):


If vehicle or trailer give registration mark:

Maximum dimensions of receptacle

Length

x Width (Give in Metres)

Location(s) where vehicle, vessel or stall is to be used as a sex establishment


I/we hereby apply to Derry City Council for the grant/renewal/transfer of a licence to use the above premises, vehicle, vessel or stall as a sex establishment.

(N.B. Any person who, in connection with this application, makes a false statement which he knows to be false in any material respect or which he does not believe to be true, shall be guilty of an offence and liable on summary conviction to a fine not exceeding £20,000.)