1Page 1 2Summary Progress Premises details Tell us which premises this representation is about. Premises name Premises address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Person making the representation Are you making this representation as: A Responsible Authority Any other person, body or business Name of service/authority First name Last name Address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Telephone number Email address Do you agree to being contacted directly by the applicant or their representative in relation to this representation? This is so they can explain the application to see if any matters can be resolved. Yes – I agree to be contacted No – I do not wish to be contacted Name and address of any representative acting for you (if applicable) (optional) Representation details Which licensing objectives is this representation relevant to? Select all that apply. (A) The prevention of crime and disorder (B) Public Safety (C) The prevention of public nuisance (D) The protection of children from harm Tell us why you support or oppose the application based on licensing objective A Tell us why you support or oppose the application based on licensing objective B Tell us why you support or oppose the application based on licensing objective C Tell us why you support or oppose the application based on licensing objective D If you would like to include any documentation in support of your representation, please upload it here (optional) To upload multiple files, hold 'Ctrl' (Windows) or 'Cmd' (Mac) when choosing files to upload. Tell us if you have any suggestions or conditions you would like the Licensing Authority or Licensing Sub-Committee to consider adding to the licence if the application is granted (optional) Declaration By submitting this form: I declare that I have read the representation guidance notes and agree that a copy of my representation will be given to the applicant / premises licence holder or their agent. I understand it is an offence to knowingly or recklessly make a false statement in connection with an application. I may be liable to an unlimited fine on conviction should such a false statement be made. Declaration confirmation I agree to the declaration statements. No information is required, please proceed to the next page. Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page Loading form summary...