Fillable Application for Renewal of (Timaru District Council New Zealand)

Fill Online, Printable, Fillable, Blank Application for Renewal of (Timaru District Council New Zealand) Form

Use Fill to complete blank online TIMARU DISTRICT COUNCIL NEW ZEALAND pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application for Renewal of (Timaru District Council New Zealand)

On average this form takes 11 minutes to complete

The Application for Renewal of (Timaru District Council New Zealand) form is 5 pages long and contains:

  • 0 signatures
  • 16 check-boxes
  • 35 other fields

Country of origin: NEW-ZEALAND
File type: PDF

Use our library of forms to quickly fill and sign your Timaru District Council New Zealand forms online.

BROWSE TIMARU DISTRICT COUNCIL NEW ZEALAND FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
#954812
Application for Renewal of
Manager’s Certificate
Sale and Supply of Alcohol Act 2012 – Section 224
For office use:
Application no: ……………………………………………
Checked: ……………………………………………
Fee paid: $316.25
Receipt no: ……………………………………………
Police: ……………………………………………
Surname: ……………………………………………
Application for Renewal of Manager’s Certificate #954812
Mackenzie, Timaru, Waimate District Licensing Committee Page 1
Application for Renewal of Manager’s Certificate
Form 19
Section 224, Sale and Supply of Alcohol Act 2012
1. Details of Applicant
Applicant title: Mr Mrs Ms Miss
Other
First name: Middle name:
Surname:
Any aliases:
Gender: Male Female
Occupation:
Date of birth: Place of birth:
Passport number: Drivers licence number:
Residential address:
Postal address (if difference from above):
Phone number: Work number:
Mobile number:
Email address:
2. Criminal Convictions
Have you ever been convicted of an offence (including traffic but not parking)?
Yes No
Note: As per the Criminal Records (Clean Slate) Act 2004, if you have no convictions in the
last 7 years, you need not declare any convictions prior to that date other than convictions
relating to imprisonment or indefinite disqualified from driving. Refer to
http://www.justice.govt.nz/privacy/clean-slate.html
If yes, give details:
Nature of offence:
Date of conviction:
Penalty suffered:
Application for Renewal of Manager’s Certificate #954812
Mackenzie, Timaru, Waimate District Licensing Committee Page 2
Nature of offence:
Date of conviction:
Penalty suffered:
Nature of offence:
Date of conviction:
Penalty suffered:
3. Employment / Training Details
Name of licensed premised at which you are currently employed / volunteering:
Address of premises:
How long have you been employed at this premises:
Please provide examples of what steps you have taken in your work to manage the sale and
supply of alcohol pursuant to the licence with the aim of contributing to the reduction of alcohol-
related harm?
Do you hold the Licence Controller Qualification (LCQ): Yes No
If yes, on what date was that qualification obtained:
4. Current Certificate Details
Managers certificate number:
Date of expiry:
Application for Renewal of Manager’s Certificate #954812
Mackenzie, Timaru, Waimate District Licensing Committee Page 3
5. Signature and Date
I acknowledge that I understand my obligations as prescribed by the Sale and Supply of
Alcohol Act 2012:
Signature of applicant:
Position:
Date:
If this form is being completed online, you will not be able, or required to sign this
form and the online lodgement will be treated as confirmation of your
acknowledgement and acceptance of the above responsibilities and liabilities and
that you have made the above representations, warranties and certification.
When complete, please email this form to the email address below.
For assistance please contact:
Liquor Licencing
Timaru District Council
2 King George Place
PO Box 522
Timaru 7940
Lodgement Email: liquoradmin@timdc.govt.nz
Phone: 03 687 7200
Payment of Fees
Please make payment at the time of lodgement to the following bank account:
Timaru District Council
02 0888 0269159 00
Reference: Mgr Cert
Particulars: Applicant name
Amount: $316.25
Application for Renewal of Manager’s Certificate #954812
Mackenzie, Timaru, Waimate District Licensing Committee Page 4
Notes
1 This application must be accompanied by the prescribed fee. Application fees are
set by the Ministry of Justice. For more information see www.justice.govt.nz
2 This application must be filed with the District Licensing Committee before the
certificate expires.
3 The New Zealand Police are required by the Sale and Supply of Alcohol Act 2012
to make inquiries into the suitability of the applicant. This will involve informing
the District Licensing Committee and the Alcohol Regulatory and Licensing
Authority of any convictions or concerns involving the applicant. Should there be
any concerns, the applicant will also be informed. By signing this form, you
consent to the release of this information.
4 Please note that a person may not be appointed as a manager of any licensed
premises unless the person is of or over the age of 20, and holds a manager’s
certificate (section 216 of the Sale and Supply of Alcohol Act 2012).
Checklist
Please read and complete this checklist BEFORE submitting the application.
Include with application form:
The original completed application.
All criminal convictions must be disclosed. Recent criminal conviction(s) may lead to
the suspending or declining of this application.
Evidence of relevant training certificate (showing unit standards 4646 and 16706) and
Licence Controller Qualification (LCQ) Certificate.
If you were not born in New Zealand you must produce proof of your right to be
working in New Zealand by means of one of the following:
− Copy of valid passport with current work permit/visa
− Copy of granting of Permanent Residence for New Zealand
−
Copy of New Zealand Citizenship
Fee of $316.25 attached (cheques made payable to Timaru District Council). If you
wish to pay online please see information on the previous page.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application for Renewal of (Timaru District Council New Zealand)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document