S.I. No. 93/1997 - District Court Rules, 1997

Dated this	day of	19	19	.	.
			Signed	Signed	......................................................
			Judge of the District Court	Judge of the District Court	Judge of the District Court

SCHEDULE NOTICE

LICENSING ACTS, 1833 TO 1988

A General Exemption Order has been granted to the holder of the on-licence in respect of these premises exempting the said holder from the provisions of the above Acts relating to prohibited hours on every week-day between the hours of

and

for the accommodation of a considerable number of persons following the lawful trade or calling of

in the vicinity of these premises.

The licence holder is bound during every period of exemption to supply on these premises food and non-alcoholic drink at reasonable prices to any person demanding the same.

No. 73.1

O.73, r.1 (5)

INTOXICATING LIQUOR ACT, 1962

Section 10

EXEMPTION ORDER FOR SPECIAL EVENT

District Court Area of	District Court Area of	District Court Area of	District Court Area of	District Court Area of	District No.
THE COURT HEREBY GRANTS to	THE COURT HEREBY GRANTS to	.................................................................................................	.................................................................................................	.................................................................................................	.................................................................................................
of	........................................................................................................................................................................,	........................................................................................................................................................................,	........................................................................................................................................................................,	........................................................................................................................................................................,	........................................................................................................................................................................,
the holder of a licence in respect of the premises situate at	the holder of a licence in respect of the premises situate at	the holder of a licence in respect of the premises situate at	......................................................................	......................................................................	......................................................................
in court area and district aforesaid, this EXEMPTION ORDER exempting the	in court area and district aforesaid, this EXEMPTION ORDER exempting the	in court area and district aforesaid, this EXEMPTION ORDER exempting the	in court area and district aforesaid, this EXEMPTION ORDER exempting the	in court area and district aforesaid, this EXEMPTION ORDER exempting the	in court area and district aforesaid, this EXEMPTION ORDER exempting the
holders of licences in the locality of such premises, namely,	holders of licences in the locality of such premises, namely,	holders of licences in the locality of such premises, namely,	holders of licences in the locality of such premises, namely,	..................................................................	..................................................................

from the provisions of the Licensing Acts relating to prohibited hours on the following days and during the following hours, to wit:-

during which period a special event, to wit:-

is being held in such locality.

IT HAVING BEEN SHOWN TO THE SATISFACTION OF THE COURT

The Court having heard the officer in charge of the Garda SIochana for the locality and also being satisfied that due notice of the application for this order was served upon such officer.

Dated this	day of	19	19	.	.
			Signed	Signed	........................................................
			Judge of the District Court	Judge of the District Court	Judge of the District Court

No. 73.2

O.73, r.2 (3)

INTOXICATING LIQUOR ACT, 1962

Section 10

ORDER REVOKING EXEMPTION FOR SPECIAL EVENT

District Court Area of	District No.

THE COURT HEREBY REVOKES the EXEMPTION ORDER granted by the

Court on the	day of	19	to ..................................	to ..................................	of	..............................................	..............................................
the holder of a licence in respect of the premises situate at	the holder of a licence in respect of the premises situate at	the holder of a licence in respect of the premises situate at	the holder of a licence in respect of the premises situate at	.................................................................	.................................................................	.................................................................	.................................................................

which exemption order exempted the holders of licences in the locality of such premises,

namely,	................................................................................................................................................

from the provisions of the Licensing Acts relating to prohibited hours on the following days and during the following hours, to wit-

during which period a special event to wit-

is being held in such locality,

IT HAVING BEEN SHOWN TO THE SATISFACTION OF THE COURT

that the application to revoke the Order had the approval of a majority of the holders of on-licences in respect of premises situate in the locality in respect of which the exemption order was made.

Dated this	day of	19	19	.	.
			Signed	Signed	........................................................
			Judge of the District Court	Judge of the District Court	Judge of the District Court

No. 73.3

O.73, r.3

O.74, r.3

O.75, r.3

INTOXICATING LIQUOR ACT, 1962

Section 25

AS SUBSTITUTED IN FIRST SCHEDULE OF THE COURTS

(NO. 2) ACT, 1986)

District Court Area of	District No.

I HEREBY CERTIFY that the list set out hereunder is a list of all the holders in respect of premises (in the said district court area) in the part of the said district court area to which the application relates, of licences now in force.

Dated this	day of	19	19	.	.
			Signed	Signed	.......................................................
			Clerk of the District Court	Clerk of the District Court	Clerk of the District Court

LIST OF PREMISES

Licence Holder	Description of Premises

No. 74.1

O.74, r.1 (6)

INTOXICATING LIQUOR ACT, 1962

Section 16

EXEMPTION ORDER FOR LICENSED BUSINESS ON SUNDAY

AFTERNOONS AND SAINT PATRICK'S DAY

District Court Area of	District Court Area of	District Court Area of	District No.
THE COURT HEREBY GRANTS to	THE COURT HEREBY GRANTS to	...................................................................................	...................................................................................
of	............................................................................................................................................................	............................................................................................................................................................	............................................................................................................................................................

the holder of a licence (not being a six day licence) in respect of the premises situate at in court area and district aforesaid,

this EXEMPTION ORDER exempting the holders of licences in the locality of such

premises, namely,	....................................................................................................................

from the provisions of the Licensing Acts relating to prohibited hours for the period between the hours of twelve o'clock and half-past twelve o'clock in the afternoon on Sundays and Saint Patrick's Day,

IT HAVING BEEN SHOWN TO THE SATISFACTION OF THE COURT

This Order shall remain in force/until the day of 19 / — (or)/until

the date of the next Annual Licensing Court for the locality/whichever is the earlier.

Dated this	day of	19	19	.	.
			Signed	Signed	.......................................................
			Judge of the District Court	Judge of the District Court	Judge of the District Court

No. 74.2

O.74, r.2 (5)

INTOXICATING LIQUOR ACT, 1962

Section 16 (5)

ORDER REVOKING EXEMPTION FOR LICENSED BUSINESS ON

SUNDAY AFTERNOONS AND SAINT PATRICK'S DAY

District Court Area of	District No.

THE COURT HEREBY REVOKES the EXEMPTION ORDER granted by the

Court on the	Court on the	day of	19	to	to	...........................................................	...........................................................
of	...................................................................................................................................................................	...................................................................................................................................................................	...................................................................................................................................................................	...................................................................................................................................................................	...................................................................................................................................................................	...................................................................................................................................................................	...................................................................................................................................................................
the holder of a licence in respect of premises situate at	the holder of a licence in respect of premises situate at	the holder of a licence in respect of premises situate at	the holder of a licence in respect of premises situate at	the holder of a licence in respect of premises situate at	...................................................................	...................................................................	...................................................................

in court area and district aforesaid,

which exemption order exempted the holders of licences in the locality of such premises,

namely,	...................................................................................................................................

from the provisions of the Licensing Acts relating to prohibited hours for the period between the hours of twelve o'clock and half-past twelve o'clock in the afternoon on Sundays and Saint Patrick's Day,

THE COURT after hearing the person to whom such exemption order was granted AND BEING SATISFIED-

Dated this	day of	19	19	.	.
			Signed	Signed	.........................................................
			Judge of the District Court	Judge of the District Court	Judge of the District Court

No. 75.1

O.75, r.1 (6)

INTOXICATING LIQUOR ACT, 1962

Section 17

ORDER PERMITTING THE OPENING AND KEEPING OPEN OF

PREMISES FOR UNLICENSED BUSINESS ON SUNDAY MORNINGS

AND SAINT PATRICK'S DAY

District Court Area of	District No.
---	---
THE COURT HEREBY GRANTS to	THE COURT HEREBY GRANTS to
of	.......................................................................................................................................................................

the holder of a licence (not being a licence granted by virtue of paragraph (2) of section 2 of the Licensing (Ireland) Act, 1902) in respect of the premises situate at

................................................................................................................................................................................

in court area and district aforesaid,

this ORDER PERMITTING the holders of licences in the locality of such premises,

namely,	...................................................................................................................................

to open or keep open their premises for the purpose of carrying on any business other than the sale or supply of intoxicating liquor during the period from .m. to

.m. (being a period not exceeding forty-five minutes in duration) on the mornings of Sundays and Saint Patrick's Day,

IT HAVING BEEN SHOWN TO THE SATISFACTION OF THE COURT

This order shall remain in force/until the day of 19 /(or) /until

the date of the next Annual Licensing Court for the locality/whichever is the earlier.

Dated this	day of	19 .	19 .	.	.
			Signed	Signed	......................................................
			Judge of the District Court	Judge of the District Court	Judge of the District Court

No. 75.2

O.75, r.2 (5)

INTOXICATING LIQUOR ACT, 1962

Section 17 (5)

ORDER REVOKING AN ORDER PERMITTING PREMISES TO OPEN OR KEEP OPEN FOR UNLICENSED BUSINESS ON SUNDAY MORNINGS AND SAINT PATRICK'S DAY

District Court Area of	District No.

THE COURT HEREBY REVOKES the order granted by the Court on the day

of 19 to	of 19 to	.............................................................................................................
of	.......................................................................................................................................................................	.......................................................................................................................................................................

the holder of a licence (not being a licence granted by virtue of paragraph (2) of section 2 of the Licensing (Ireland) Act, 1902) in respect of the premises situate at

.........................................................................................................................................................

in court area and district aforesaid,

PERMITTING the holders of licences in the locality of such premises, namely,	..............................	..............................
..........................................................................................................................................................	..........................................................................................................................................................	to open or keep

open their premises for the purpose of carrying on any business other than the sale or supply of intoxicating liquor during the period from .m. to .m. (being a period not exceeding forty-five minutes in duration) on the mornings of Sundays and Saint Patrick's Day,

THE COURT after hearing the person to whom such order was granted AND BEING SATISFIED-

Dated this	day of	19	.
			Signed.............................................................
			Judge of the District Court

No. 76.1

O.76, r.1 (3)

INTOXICATING LIQUOR ACT, 1962

SECTION 11 (AS AMENDED)

OCCASIONAL LICENCE

District Court Area of	District No.
---	---
THE COURT HEREBY GRANTS to	THE COURT HEREBY GRANTS to
of	.....................................................................................................................................................................
the holder of an on-licence in respect of the premises	the holder of an on-licence in respect of the premises
situate at	situate at
this OCCASIONAL LICENCE authorising the sale of intoxicating liquor at	this OCCASIONAL LICENCE authorising the sale of intoxicating liquor at
........................................................................................................	........................................................................................................

place to which no licence for the sale of intoxicating liquor is attached, between the hours of .m. on the day of 19 and .m. on the day of 19 on the occasion of

subject to the restrictions contained in section 11 of the Intoxicating Liquor Act, 1962

THE COURT BEING SATISFIED that due notice of the application for the licence was served upon the officer in charge of the Garda Síochána for the locality to which this licence relates.

Dated this	day of	19	.
			Signed..............................................................
			Judge of the District Court

No. 77.1

O.77, r.1 (3)

FORM OF ENDORSEMENT OF AD INTERIM TRANSFER OF LICENCE

District Court Area of	District No.

THE COURT, pursuant to section 1 of the Public Houses (Ireland) Act, 1855 (as applied to off-licences by section 29 of the Intoxicating Liquor Act, 1960 ) HEREBY

TRANSFERS the within licence from	TRANSFERS the within licence from	.......................................................................................
to	..................................................................................................................................................................	..................................................................................................................................................................

until the next sitting of the Annual Licensing Court to be held next after the expiration of one month from the date hereunder.

Dated this	day of	19	.
			Signed...............................................................
			Judge of the District Court

No. 77.2

O.77, r.3 (2)

INTOXICATING LIQUOR ACT, 1960

Section 30

NOTICE OF APPLICATION FOR AD-INTERIM TRANSFER OF A LICENCE TO PERSON OTHER THAN THE OWNER

District Court Area of	District No.	District No.
....................................................................................................................................................................	....................................................................................................................................................................	Applicant
---	---	---
TAKE NOTICE that	TAKE NOTICE that	................................................................................................................
of	............................................................................................................................................................	............................................................................................................................................................
intends to apply to the Court at	intends to apply to the Court at	intends to apply to the Court at

on the day of 19 at .m. for an AD INTERIM TRANSFER of

the licence attached to the premises situate at	the licence attached to the premises situate at	the licence attached to the premises situate at	..................................................................................	..................................................................................
.......................................................................................................	.......................................................................................................	.......................................................................................................	.......................................................................................................	in court area and district aforesaid
from	from	................................................................................................................................................	................................................................................................................................................	................................................................................................................................................
of	...................................................................................................................................................	...................................................................................................................................................	...................................................................................................................................................	...................................................................................................................................................

(who for reasons other than death, transfer of the premises or forfeiture of the licence has ceased to carry on the business authorised by the licence)

to	...................................................................................................................................................
of	..................................................................................................................................................
---	---
Dated this	day of

To the Superintendent of the Garda Síochána,

at

No. 77.3

O.77, r.3 (2)

INTOXICATING LIQUOR ACT, 1960

Section 30

NOTICE OF APPLICATION FOR A CERTIFICATE FOR THE RENEWAL OF A LICENCE IN CASES WHERE THE OWNER HAS CEASED TO CARRY ON BUSINESS

District Court Area of	District No.	District No.
....................................................................................................................................................................	....................................................................................................................................................................	Applicant
---	---	---
TAKE NOTICE that	TAKE NOTICE that	.................................................................................................................
of	............................................................................................................................................................	............................................................................................................................................................
intends to apply to the Court at	intends to apply to the Court at	intends to apply to the Court at

on the day of 19 at .m. for a certificate for the RENEWAL

of the * licence attached to the premises situate at	...........................................................................	...........................................................................
.....................................................................................................	.....................................................................................................	in court area and district aforesaid,

which licence expired on the day of 19 and the holder of such licence has ceased, for reasons other than death, transfer of the premises or forfeiture of the licence, to carry on the business authorised by the licence.

Dated this	day of	19	.
			Signed..............................................................
			Applicant or Solicitor for Applicant

To the Superintendent of the Garda Síochána,

at

• Describe nature of licence

No. 77.4

O.77, r.3 (4)

FORM OF ENDORSEMENT OF AD-INTERIM TRANSFER OF LICENCE

(to person other than the owner)

District Court Area of	District No.

THE COURT, pursuant to sub-section 1 (a) of section 30 of the Intoxicating Liquor

Act, 1960, HEREBY TRANSFERS the within licence from	Act, 1960, HEREBY TRANSFERS the within licence from	....................................................................
to	........................................................................................................................................................................	........................................................................................................................................................................

*(until the next sitting of the Annual Licensing Court to be held next after the expiration of one month from the date hereunder)

*(until the sitting of the Annual Licensing Court to be held on the day of 19 .

Dated this	day of	19	.
			Signed.............................................................
			Judge of the District Court

• Delete whichever inapplicable

No. 77.5

O.77, r.3 (5)

O.80, r.8

INTOXICATING LIQUOR ACT, 1960

Section 30 (1) (b)

COURTS (No. 2) ACT, 1986

Section 4

CERTIFICATE FOR RENEWAL OF LICENCE

District Court Area of	District No.
---	---
UPON HEARING AN APPLICATION made by	UPON HEARING AN APPLICATION made by
of	.........................................................................................................................................................................
for a certificate for the renewal of the *	for a certificate for the renewal of the *
licence in respect of the premises	licence in respect of the premises
situate at	situate at

THE COURT HEREBY GRANTS to the applicant

THIS CERTIFICATE certifying to the good character of the said applicant † (and to the peaceable and orderly manner in which the said premises were conducted in the past year).

Dated this	day of	19	.
			Signed.............................................................
			Judge of the District Court

• Describe nature of licence

† Delete where no business has been carried on in the premises at any time during the past year.

No. 78.1

O.78, r.1 (3)

FORM OF ENDORSEMENT OF TRANSFER OF LICENCE HELD BY NOMINEE

District Court Area of	District No.

THE COURT, pursuant to section 28 of the Intoxicating Liquor Act, 1960 HEREBY

TRANSFERS the within licence from	TRANSFERS the within licence from	.............................................................................................
to	...........................................................................................................................................................	...........................................................................................................................................................

being the person nominated by the body corporate to wit:-

Dated this	day of	19	.
			Signed.............................................................
			Judge of the District Court

No. 79.1

O.79, r.5

LICENSING (IRELAND) ACT, 1833

Section 6

INTOXICATING LIQUOR ACT, 1960

Section 29

CERTIFICATE OF TRANSFER OF A LICENCE

District Court Area of	District Court Area of	District Court Area of	District Court Area of	District Court Area of	District Court Area of	District No.	District No.
I,	..............................................................................................	..............................................................................................	..............................................................................................	..............................................................................................	Clerk of the District Court for the court area	Clerk of the District Court for the court area	Clerk of the District Court for the court area
aforesaid do hereby certify that	aforesaid do hereby certify that	aforesaid do hereby certify that	.....................................................................................................	.....................................................................................................	.....................................................................................................	.....................................................................................................	.....................................................................................................
of	...........................................................................................................................................................	...........................................................................................................................................................	...........................................................................................................................................................	...........................................................................................................................................................	...........................................................................................................................................................	...........................................................................................................................................................	...........................................................................................................................................................
is entitled to receive a *	is entitled to receive a *						licence
in respect of the premises situate at †	in respect of the premises situate at †	in respect of the premises situate at †	in respect of the premises situate at †	.................................................................................................	.................................................................................................	.................................................................................................	.................................................................................................

in court area and district aforesaid.

Dated this	day of	19	.
			Signed..............................................................
			Clerk of the District Court for the court area aforesaid

• Describe nature of licence

† Describe premises and situation thereof specifying townland, or if in a town the street and the number of the premises and County.

No. 80.1

O.80, r.3 (1)

COURTS (No. 2) ACT, 1986

Section 4

NOTICE OF OBJECTION TO RENEWAL OF INTOXICATING LIQUOR LICENCE

District Court Area of	District No.	District No.
......................................................................................................................................................................	......................................................................................................................................................................	Objector
---	---
TAKE NOTICE that the above-named objector, of	.....................................................................
will object at the sitting of the District Court to be held at	....................................................................

on the day of 19 at a.m./p.m. to the RENEWAL of the

*	licence attached to the premises situate at	..................................................

in court area and district aforesaid on the following grounds:-

Dated this	day of	19	.
			Signed............................................................
			Objector/Solicitor for Objector

To

of

(the holder of the licence attached to the above premises).

• Describe nature of licence

No. 80.2

O.80, r.4

COURTS (No. 2) ACT, 1986

Section 4

NOTIFICATION OF THE LODGMENT OF A NOTICE OF OBJECTION TO THE RENEWAL OF AN INTOXICATING LIQUOR LICENCE

District Court Area of	District No.
---	---
YOU ARE HEREBY NOTIFIED that	YOU ARE HEREBY NOTIFIED that
of	.................................................................................................................................................................

has lodged a notice of objection to the renewal of the *

licence attached to the premises situate at	..........................................................................................

in court area and district aforesaid.

The holder of the licence attached to the said premises is	The holder of the licence attached to the said premises is	The holder of the licence attached to the said premises is	...................................................................	...................................................................
of	..................................................................................................................................................................	..................................................................................................................................................................	..................................................................................................................................................................	..................................................................................................................................................................
and the objection has been listed for (hearing at) the sitting of the District Court to be	and the objection has been listed for (hearing at) the sitting of the District Court to be	and the objection has been listed for (hearing at) the sitting of the District Court to be	and the objection has been listed for (hearing at) the sitting of the District Court to be	and the objection has been listed for (hearing at) the sitting of the District Court to be
held at	held at	.......................................................................................	.......................................................................................	on the day of 19

at a.m./p.m.

RENEWAL OF SUCH LICENCE SHOULD NOT BE GRANTED RENDING THE DECISION OF THE COURT UPON SUCH OBJECTION.

Dated this	day of	19	.
			Signed............................................................
			Clerk of the District Court

To the Collector of Customs and Excise,

at	................................................................................................................................................

• (and)

(To the Superintendent of the Garda Síochána,

at	.................................................................................................................................................)

• Describe nature of licence

No. 80.3

O.80, r.5 (1)

ORDER ON HEARING OBJECTION TO THE RENEWAL OF INTOXICATING LIQUOR LICENCE

District Court Area of	District Court Area of	District No.
...................................................................................................................................................	Objector	Objector
....................................................................................................................................................	Licence Holder	Licence Holder

UPON THE HEARING by the Court on the day of 19of an objection by the above-named objector of

to the renewal by an officer of the Revenue Commissioners of the *

licence attached to the premises situate at

in court area and district aforesaid, made on the grounds that-

the Licence holder of which premises is ,

of

† THE COURT ORDERED on the day of 19 that the said

objection

† BE ALLOWED

† BE DISALLOWED.

Dated this	day of	19	.
			Signed.............................................................
			Judge of the District Court

• Describe nature of licence

† Delete whichever inapplicable

No. 80.4

O.80, rr.5 (3), 8

LICENSING ACTS, 1833 TO 1988

COURTS (No. 2) ACT, 1986

Section 4

CERTIFICATE FOR RENEWAL OF LICENCE

District Court Area of	District No.

THE COURT HEREBY GRANTS TO

of

the holder of a *	licence attached

to the premises

situate at

	in court area and district aforesaid,

THIS CERTIFICATE certifying to the good character of the said licence holder and to the peaceable and orderly manner in which the said licensed premises were conducted in the past year;

(Add the following recital where the premises are in a holiday camp)

and to the orderly manner in which the holiday camp (within the meaning of Chapter III of Part V1 of the Tourist Traffic Act, 1952 ) in which the said premises are situate was conducted in the past year:

(Add the following condition where the certificate is for the renewal of a six-day licence)

It shall be a condition of this certificate that the said licence holder shall keep the said licensed premises closed during the whole of Sunday;

(Add the following condition where the certificate is for the renewal of an early closing licence)

It shall be a condition of this certificate that the said licence holder shall close the said licensed premises one hour earlier at night than that at which such premises would otherwise have to be closed.

Dated this	day of	19	.
			Signed...............................................................
			Judge of the District Court

• Describe nature of licence

No. 82.1

O.80, r.1

REGISTER OF LICENCES

District Court Area of	District No.
---	---
Description and Situation of Licensed Premises	Date and Description of Licence

No. 82.2

O.82, r.2

NOTICE DESCRIBING LICENSED PREMISES

District Court Area of	District No.
---	---
Name of Licence Holder	Name of Licence Holder
(Full Christian names and Surname should be given)	(Full Christian names and Surname should be given)
Address	..............................................................................................................................................................
Description and Location of the House or Premises at which intoxicating liquors are	Description and Location of the House or Premises at which intoxicating liquors are
licensed to be sold	licensed to be sold
Name of Owner of Premises	Name of Owner of Premises
(Full Christian names and Surname should be given)	(Full Christian names and Surname should be given)
Address of Owner of Premises	Address of Owner of Premises
I hereby certify that the foregoing particulars are correct.	I hereby certify that the foregoing particulars are correct.

To the Clerk of the District Court,

at	........................................................

No. 83.1

O.83, r.3 (1),4 (1)

REGISTRATION OF CLUBS ACTS, 1904 TO 1988

APPLICATION FOR † (RENEWAL OF) CERTIFICATE OF REGISTRATION

District Court Area of	District No.	District No.
.............................................................................................................................................................	.............................................................................................................................................................	Applicant
---	---	---
I	.................................................................................	.................................................................................
Secretary of	Secretary of	................................................................................................
are situated at	are situated at	are situated at

in court area and district aforesaid,

hereby apply for a † (renewal of the) Certificate of Registration of the above mentioned Club.

The object of the said Club is	.........................................................................................................................
..............................................................................................................................................................................................	..............................................................................................................................................................................................
..............................................................................................................................................................................................	..............................................................................................................................................................................................

I enclose the following documents-

( a ) A certificate signed by two Peace Commissioners *(and by the owner of the premises).

( b ) Two copies of the Club Rules.

( c ) A list of the NAMES IN FULL (not initials) and addresses of the officials and Committee of Management or governing body of the Club.

( d ) A list of the names of the members of the Club.

( e ) The prescribed Court fee.

Dated this	day of	19	.
			Signed.........................................................................
			Secretary of the above Club
			Club Solicitors............................................................

To the Registrar of Clubs,

District Court Office,

at	.................................

† Delete if not required

• Delete where premises are owned by Club

No. 83.2

O.83, r.4 (3) (c)

REGISTRATION OF CLUBS ACTS, 1904 TO 1988

CERTIFICATE TO ACCOMPANY APPLICATION FOR † (RENEWAL OF)

CERTIFICATE OF REGISTRATION

District Court Area of	District No.
---	---
We, Peace Commissioners for	We, Peace Commissioners for
*(and I,	.............................................................................................................................................

premises occupied by the Club hereinafter mentioned)

hereby certify that, to the best of our knowledge and belief, the	.......................................................................

Club designated in the accompanying application has been and is to be conducted as a bona fide Club, and not mainly for the supply of excisable liquor.

	Signed	.......................................................................	.......................................................................	.......................................................................	.......................................................................	.......................................................................	.......................................................................	.......................................................................
	Peace Commissioner	Peace Commissioner	Peace Commissioner	Peace Commissioner	Peace Commissioner	Peace Commissioner	Peace Commissioner	Peace Commissioner
	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................
	Date .................................................................................	Date .................................................................................	Date .................................................................................	Date .................................................................................	Date .................................................................................	Date .................................................................................	Date .................................................................................	Date .................................................................................
	Signed .............................................................................	Signed .............................................................................	Signed .............................................................................	Signed .............................................................................	Signed .............................................................................	Signed .............................................................................	Signed .............................................................................	Signed .............................................................................
	Peace Commissioner	Peace Commissioner	Peace Commissioner	Peace Commissioner	Peace Commissioner	Peace Commissioner	Peace Commissioner	Peace Commissioner
	Address .........................................................................	Address .........................................................................	Address .........................................................................	Address .........................................................................	Address .........................................................................	Address .........................................................................	Address .........................................................................	Address .........................................................................
	Date	.......................................................................	.......................................................................	.......................................................................	.......................................................................	.......................................................................	.......................................................................	.......................................................................
	*Signed ..........................................................................	*Signed ..........................................................................	*Signed ..........................................................................	*Signed ..........................................................................	*Signed ..........................................................................	*Signed ..........................................................................	*Signed ..........................................................................	*Signed ..........................................................................
	Owner of Club Premises	Owner of Club Premises	Owner of Club Premises	Owner of Club Premises	Owner of Club Premises	Owner of Club Premises	Owner of Club Premises	Owner of Club Premises
	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................	Address ..........................................................................
	Date .................................................................................	Date .................................................................................	Date .................................................................................	Date .................................................................................	Date .................................................................................	Date .................................................................................	Date .................................................................................	Date .................................................................................

† Delete if not required

• Delete where premises is owned by Club

No. 83.3

O.83, r.3 (1),4 (6)

REGISTRATION OF CLUBS ACTS, 1904 TO 1988

NOTICE OF LODGMENT OF APPLICATION FOR † (RENEWAL OF)

CERTIFICATE OF REGISTRATION

District Court Area of	District No.

TAKE NOTICE that application for † (renewal of) a Certificate of Registration under