This form can be completed and submitted by the applicant, or the applicant’s agent (for example, solicitor), providing they have authority to do so.

Enter a point of contact for this application. This is where we will send all correspondence, including payment information.

I/We as named above, as the premises licence holder, are applying to vary a premises licence to specify the individual named in this application as the premises supervisor under section 37 of the Licensing Act 2003 for the premises described in this application.

Premises address

Section 37(4)(b) of the Licensing Act 2003 requires the premises licence holder to notify the existing designated premises supervisor (if any) about this application. It is sufficient for the licensee to inform the existing DPS in writing, without the need to share the specific details of the application. The notice should state whether section 38 of that Act (circumstances in which section 37 application given interim effect) applies to this application.

I/We understand that it is an offence, under section 158 of the Licensing Act 2003, to make a false statement in or in connection with this application. Those who make a false statement may be liable on summary conviction to a fine of any amount.

It is an offence under section 24b of the Immigration Act 1971 for a person to work when they know, or have reasonable cause to believe, that they are disqualified from doing so by reason of their immigration status. Those who employ an adult without leave or who is subject to conditions as to employment, will be liable for a civil penalty under section 15 of the Immigration, Asylum and Nationality Act 2006 and, pursuant to Section 21 of the same act, will be committing an offence where they do so in the knowledge, or with reasonable cause to believe, that the employee is disqualified by virtue of their immigration status.