Tower Hamlets



|FOR OFFICE USE |

|RECEIPT / INVOICE NO. |FEE REQUIRED: |Date: |Initials: |

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|On-Line Payment Ref: |£10.50 | | |

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|This is an application for a change of name and/or address for a Personal Licence Holder, please complete the information as required.|

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|This form should be completed and forwarded with the relevant documents to: Licensing Section, Mulberry Place (AH), PO BOX 55739,5 |

|Clove Crescent,London E14 1BY, with a cheque for the correct fee, made payable to the London Borough of Tower Hamlets. |

|On-Line payments can be made at: |

|Or alternatively from  under 'Online Services'  |

|Application for Change of Name/Address of a Personal Licence Holder |

|1. Your Personal Licence Details |

|PREVIOUS NAME – please enter details of any previous name. |

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|TITLE (Mr\ Mrs\ Miss\Ms\ Other\) |

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|Surname | |

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|Forenames | |

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|Personal Licence Number: |

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|Previous Address | |

|(WHERE ORDINARILY RESIDENT) | |

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|NEW ADDRESS | |

|(WHERE ORDINARILY RESIDENT) | |

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|Address for correspondence associated with this application (if different to the address above) |

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|TELEPHONE NUMBERS |

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|Daytime | |

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|Evening | |

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|Mobile | |

|EMAIL ADDRESS (if you would prefer us to correspond with you by e-mail) |

|4. CHECKLIST: |

| |Please tick βyes |

|I have | |

|• enclosed the paper licence |[pic] |

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|• enclosed the personal licence |[pic] |

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|• enclosed a fee of £10.50 |[pic] |

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|• enclosed copies of supporting documents for change of name |[pic] |

|i.e. marriage certificate/ divorce certificate/ deadpoll | |

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|If you can not provide the licence please state the reason why | |

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|SIGNATURE |DATE |

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Your amended licence and card will be forwarded to you as soon as possible.

NOTES

Information on the Licensing Act 2003 is available on the website of the Department for Culture, Media and Sport () or from your local licensing authority.

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Licensing Act 2003

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