| Section 24(2) |
| (To be completed in duplicate). |
| APPLICATION FOR REMOVAL OF A LIQUOR LICENCE TO ANOTHER PREMISES. |
| (Under the provisions of the Liquor Licensing Act) |
| .......................... |
| (Date) |
| To: The Magistrate, |
| Licensing District No ................................ |
| I .......................................... of ............................................ holder of a |
| (state address) |
| licence in respect of premises situate at ............................................ hereby make application for transfer of the said licence to new premises situate at ............................. |
| 2. | Particulars of new premises |
| (1) | Do these premises occupy an entire building? | .................................... |
| (Answer “Yes” or “No”) |
| (2) | If “No”, what is the rest of the building used for? | .................................... |
| (3) | Do you live “In” or “Near” the premises? | .................................... |
| (Answer “In” or “Near”) |
| (4) | If “Near”, how far? | .................................... |
| (5) | Number of rooms contained in the premises | .................................... |
| (6) | Number of doors | .................................... |
| (7) | Number of windows | .................................... |
| 3. | (1) | Have you applied for a Certificate before? | .................................... |
| (Answer “Yes” or “No”) |
| (2) | What was the result | |
| (Answer “Granted” or “Refused”) |
| (3) | If “Refused”, state why | .................................... |
| .................................... |
| (Signature of Applicant). |
| 4. | Number of other licensed premises in your village street or road | .................................... |
| Or |
| Number of licensed premises within the radius of a mile? | .................................... |
| Average number of dwellings within the radius of a mile | .................................... |
| Average number of persons residing within the radius of a mile? | .................................... |
| Signature of Commissioner of Police. |