(CONFIRM THE FORMAT THAT MUST BE USED FROM YOUR LIQUOR AUTHORITY)
DATE: (Date of Placement of Notice for Public.)
Notice is hereby given that it is the intention of the person whose details are set out below to lodge an application for a LIQUOR STORE LICENSE (Type of Liquor License Applied for) to the secretary of the local committee / liquor authority at (Full Address of Authority where Application will be Submitted) on (Date of Submission of Application).
1 Full name of applicant: Business Name or Applicant Name
- Intended Trading Name: Name of Store / Shop / Business
- Identity Number or Registration number of the applicant: ____
- Full address and location of the premises: (Include Full Address of Premises / Erf Number as per Zoning Certificate).
- Type of license applied for: (Type of License Applied for).
- Name and nature of educational institutions within a radius of 500 meters from the premises in paragraph 4: (Names of Educational Institutions / NONE if none).
- Names and distances to similar licensed premises within a radius of 500 meters from the premises in paragraph 4. (Names of Similar Licensed Premises / NONE if none).
- Places of worship within a radius of 500 meters from the premises in paragraph 4: (Names of Places of Worship / NONE if none).
- Notices Published in Government Gazette and 2 Public Newspapers: YES / NO
- REFERENCE NUMBER OF APPLICATION (AS GIVEN BY LIQUOR BOARD / LIQUOR AUTHORITY)
Contact Details of Applicant: (Name, Residential Address and Correspondence eMail Address of Applicant).
Signature of Applicant.
I certify that this declaration has been signed and sworn before me at ______________________ this ___ day of ______ 2016 by the person authorised to sign on behalf of the license holder who acknowledged that:-
he/she knows and understands the contents of the declaration;
he/she has no objection to taking the prescribed oath; and
he/she considers the prescribed oath to be binding on his conscience.
“I swear that the contents of this declaration are true, so help me God”
Commissioner of Oath.