Change of name or address for the DPS on a Premises Licence

Change of name/address for a Designated Premises Supervisor
Fields marked with * are required
I wish to notify the Licensing Team at Breckland Council of*
1. change of name of the Designated Premises Supervisor (DPS) for a Premises Licence
2. new address of the Designated Premises Supervisor (DPS) for a Premises Licence
3. both
Change of name
2. DPS previous name
3. DPS new full name
4. Date effective from (DD/MM/YYYY)
5. Reason for change
6. Please upload proof of change of name (for example marriage certificate/deed poll certificate)
  Permitted file types: JPEG, PNG, PDF. Maximum file size: 5MB
Change of address
2. DPS Full name
3. DPS previous address
4. Postcode
5. DPS new address
6. Postcode
7. DPS Telephone number
8. Date effective from (DD/MM/YYYY)
Return licence details
1. Please return the premises licence to Licensing Team, Breckland Council, Elizabeth House, Walpole Loke, Dereham, NR19 1EE
2. I will return the the original premises licence *
  
  Yes
  
  No
3. If you will are not able to return the premises licence, please give reasons why not

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