APPLICATION BY THE PROPRIETOR OF A PLEASURE BOAT

FOR LICENCE TO OPERATE

Full Name(s) & Address of Applicant……………………………………….

If more than one applicant please……………………………………….

supply details on separate sheet

……………………………………….

……………………………………….

Post Code: ………………………..

Registered Company Address:……………………………………….

……………………………………….

……………………………………….

Post Code: ………………………..

Daytime Contact Telephone Numbers:

Landline: ………………………………………………

Mobile Telephone: …………………………………..

Email Address(es): ………………………………………………………………………...…

Availability for Contact:

(eg best time of day, days of week when on site, whether to use email, telephone, visit etc)

………………………………………………………………………………………………………...

…………………………………………………………………………………………………………

Date of Birth ………………………. [Please use format: DD/MM/YYYY]

Location of Boats/Craft: ……………………………………………………………......

…………………………………………………………………………………………………………

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continued over/….

SCHEDULE OF PLEASURE BOATS

TYPE OF CRAFT / IDENTIFYING NUMBER OR MARK / NAME OF CRAFT IF APPLICABLE / MAXIMUM NUMBER OF PERMITTED PASSENGERS

Declaration

IN PURSUANCE of Public Health Acts Amendment Act 1907 I hereby apply for the grant of a Licence to Operate Pleasure Boats, the details of which are given in the Schedule of Pleasure Boats above.

I understand that the licence, if granted, may be suspended or revoked, or endorsed by the District Council whenever it shall deem such suspension, revocation or endorsement to be necessary or desirable in the interest of public safety or in the event of any breach of the conditions to the said licence.

SIGNATURE(S)………………………………………………… DATE……………………………..

……………………………………………………………………. DATE …………………………….

THE INFORMATION SUPPLIED ON THIS APPLICATION FORM MAY BE DIVULGED TO THE POLICE AND OTHER AGENCIES INVOLVED IN THE PREVENTION OF FRAUD.

NOTES

The completed form should be returned to: The Licensing Team, Town Hall, Matlock, Derbyshire, DE4 3NN.

You can email your application to: and telephone 01629 761313 to make the payment. The Council no longer accepts cheque or cash payment for licence application fees.

In the event that this application is refused the licence application fee will be retained to cover administration costs.

FOR INFORMATION:

Please see attached Guidance Notes, and Conditions that will be attached to licence if granted.

Office Use:

Date application received and accepted as complete ……………………..

Fee paid (Amount) £...... Receipt Number ………………………..

M3 Worksheet Number ………………………….. Date passed to EH ……………………

Revised: RS/LT/ET/March 2018

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