Application for permission to hold a public charitable collection

1. Organiser Details

Full Name of applicant

Title

First Name

Surname

Address of applicant

Address

Address 2

City/Town

Post Code

E-mail

Date of birth of applicant

Business hours telephone number of applicant

2. Details of charity

Particulars of charitable purposes to which proceeds of collection are to be applied.

Attach charitable accounts

Full particulars should be given and where possible, the most recent accounts of any charity which is to benefit should be enclosed.
Maximum 3 files.
8 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, rtf, pdf, doc, docx, xls, xlsx.

Charity Number

3. Collection area

Over what parts of the Licensing area is it proposed the collection should be made?

4. Collection Dates

Date(s) during which it is proposed that the collection should be made

5. Collection staff

Approximately how many persons is it proposed to authorise to act as collectors in the area of the Licensing Authority?

How will they be identified?

6. Collection Staff Remuneration

To collectors

Yes

If so, at what rates and to what classes of person?

To other persons

Yes

If so, at what rates and to what classes of person?

7. Previous Applications

Was a previous application refused?

Has the applicant or, to the knowledge of the applicant, anyone associated with the promotion of the collection been refused a license or order under the Act, or had a license or order revoked?

Yes

Name of licensing authority

Date of refusal

Details of refused application

Has the applicant been convicted of any crime or offence?

Yes

Please give details

I declare that particulars given by me on this form are, to the best of my knowledge and belief, correct

Name of applicant

NOTE:

1. Any form lodged which has not been fully completed will not be able to be processed and will be returned to the applicant.

2. THE COMPLETED APPLICATION FORM MUST BE LODGED AT LEAST 28 DAYS PRIOR TO THE PROPOSED DATE OF COLLECTION.

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