| Section 6 |
| REPORT ON APPLICATION FOR CERTIFICATE FOR LICENCE TO SELL INTOXICATING LIQUOR |
| (Under the provisions of section .................................... of the Liquor Licensing Act) |
| ...................................... |
| (Date) |
| 1. | Name of Applicant .......................................................................... |
| 2. | Address of proposed premises .............................................................. |
| 3. | Are there any convictions against the applicant? ........................................... |
| (Answer “Yes” or “No”) |
| 4. | If “Yes”, state offences and dates of convictions ........................................... |
| 5. | Particulars of proposed 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) | Number of rooms contained in the premises? | .............................................. |
| (4) | Number of doors? | .............................................. |
| (5) | Is there any internal communication between the proposed premises and any other building or any part of a building? | .............................................. |
| 6. | By what means is water supplied to the proposed premises? | .............................................. |
| 7. | Are the proposed premises situate within 200 yards of any school or church or place of public worship? | .............................................. |
| (a) | Are there any other licensed premises in that street, road or village, if so state number in street, road village as the case may be | .............................................. |
| or | | |
| (b) | Number of licensed premises within the radius of a mile? | .............................................. |
| (c) | Average number of dwellings within the radius of a mile? | .............................................. |
| (d) | Average number of persons residing within the radius of a mile? | .............................................. |
| 8. | From your enquiries, what is the applicant's general reputation in the area where the proposed premises are situate? | .............................................. |
| 9. | Other enquiries | .............................................. |
| 10. | Remarks or observations | .............................................. |
| .............................................. |
| Signature of Police Officer making Report. |