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Licensing Act Notification form

Fields marked with * are required
Notification Details
1. What is the notification for?*
  
  Report Bankruptcy
  
  Cancel Temporary Event Notice (TEN)
  
  Report Conviction or Offence Committed
  
  Surrender Licence
  
  Report Death of Licence Holder
2. What licences do you hold?
  
  DPS (Designated Premises Supervisor)
  
  Personal Licence
  
  Premises Licence
  
  Club Premises Certificate
  
  Not Applicable
3. Full information on surrendering your licence is available on the Breckland website.
  
  Surrender of Premises Licence or CPC
  
  Surrender of a Personal Licence
  
  Breckland Council will not issue any refunds for any remaining licence period.
4. Please provide date of death or bankruptcy
5. Premises/CPC Address
6. Licence Number*
7. Please provide details of the notification*
8. Please upload any relevant images/documents
  Permitted file types: JPEG, PNG, PDF. Maximum file size: 5MB
Your details
1. Name*
2. Email*
3. Contact Telephone Number
4. Are you completing this form on behalf of someone else?*
  
  Yes
  
  No
5. Assisted service details
  1. In what capacity are you completing this form?
    
    CC Staff
    
    Agent/Solicitor
    
    Relative/Friend
    
    Carer
    
    Other
  2. Name of person completing this online form
  3. Email of person completing this form
Privacy statement

Breckland Council is collecting this information, via this form, in order to perform this service or function, and if further information is needed in order to do so, you may be contacted using the details provided.

In performing this service, the Council may share your information with other organisations or departments, but only when it is satisfied that it is necessary to perform a public task, or to exercise its statutory duties to do so.

The Council may also share your personal information for the purposes of the prevention, investigation, detection, or prosecution of criminal offences, but will not share your personal information, or use it for any other purpose, unless provided for by law.

More detailed information about the Council's handling of your personal data can be found in our privacy policy.

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We've made some updates to our website!

Licensing Act Notification form

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Licensing Act Notification form

Privacy statement

Is this page useful?