Online Form - Application for SECTION 39 Certificate of Local Health Authority

Property this application relates to

Name of Premises*

Property Address (lot, street no, street name, suburb)*

Applicant Details

Applicant's name*

Premises/Business*

Postal Address*

Suburb*

Postcode*

Phone No*

Mobile Phone Number*

Fax

Email Address

Full name*

Date*

Licensee’s details (if different to Applicant)

Licensee's name/s

Postal Address

Phone Number

Mobile Phone Number

Email Address

Full name

Date

Alcohol to be served

Please check the following*

RTD’s canned & bottled
Wine
Bottled beer
Mixed spirits
Beer on tap
Other

If Other, please put details here

Category and type of licence*

Nature of application and an outline of the proposed use of the premises*

In the case of a SPECIAL FACILITY LICENCE application

(a) For what purpose is the licence sought (refer to regulation 9A of the liquor control regulations 1989)*

(b) What trading hours are sought?

Please select the start and finish times for the days you wish to trade.

Monday start time

Monday finish time

Tuesday start time

Tuesday finish time

Wednesday start time

Wednesday finish time

Thursday start time

Thursday finish time

Friday start time

Friday finish time

Saturday start time

Saturday finish time

Sunday start time

Sunday finish time

(c) Is approval sought to sell & supply liquor on:

Christmas Day*

YesNo

Good Friday*

YesNo

Anzac Day*

YesNo

(d) Is approval sought to sell and supply liquor for consumption off the licenced premises?*

YesNo

(e) Please detail the trading conditions sought and provide an outline on how it is proposed the premises will operate (attach separate submission if necessary)*

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