/ BROXTOWE BOROUGH COUNCIL

LOCAL GOVERNMENT (MISCELLANEOUS PROVISIONS) ACT 1976

PRIVATE HIRE OPERATOR APPLICATION/RENEWAL
Your Details
1 / Name in which licence is to be held
(Individual or Partnership)
2 / Address
Post Code
Telephone Number
Mobile Number
3 / Trading Name
4 / Operating Address
Post Code
5 / Telephone Number
6 / Email Address
7 / Is there current planning permission forthe use of these premises for this purpose / Yes / No
Registered Companies Only Please complete this section
8 / Company No.
9 / Registered Office Address
(if same as 4 write as above)
Post Code
Telephone Number
Please attach a list of names and addresses of directors.
Please attach a copy of your certificate of incorporation.
10 / Complete as applicable
(a) / Has a Private Hire Operator’s Licence been previously held by you or your partners or by any company of which you have been a Director or Secretary in this or any other Area? / Yes / No
(b) / Is this application for a renewal of a Private Hire Operators Licence? / Yes / No
If YES please give details of the Licence No.
Expiry Date
(c) / Do you, your partner or your company currently hold a PSV Operator’s Licence in this or any other area? / Yes / No
If YES Which Area(s)
11 / Has any previous Private Hire Operator’s Licence, Hackney Carriage/Private Hire Vehicle Licence or Hackney Carriage/PrivateHire Driver’s Licence held by you or your partners or any company ofwhich you have been a Director or Secretary, been refused, revoked or suspended? / Yes / No
If YES to the above question please give details on a separate sheet
12 / Please provide details of two referees who are prepared to support your application.
N.B. The referees should have known you for two to three years and not be a member of your family. One reference should be from a Business Proprietor or person of similar standing.
References are not required if the application is for the renewal of a licence.
(1) / Name
Address
Post Code
Telephone No.
(2) / Name
Address
Post Code
Telephone Number
13 / Fee
Note:Three Year Licence / 1 vehicle / £96.25
2 – 5 / £187.00
6 – 10 / £399.25
11 – 15 / £675.50
16 – 20 / £896.25
21 or more / £1293.75
Declarations
14. / Have you or your partners ever been made bankrupt? / Yes / No
15 / Have you or your partners or directors been involved with a company which has gone into insolvent liquidation? / Yes / No
16 / Have you or any of your directors been disqualified from
acting as a director or taking part in the management of a
company? / Yes / No
If YES to any of the above questions please give details on a separate sheet
17 / Have you, your partner(s), the Company directors or Secretary any convictions whichunder the terms of the Rehabilitation of Offenders Act 1974, are not spent? / Yes / No
If YES to the above question, please give details on a separate sheet

I have read the conditions subject to which this application will be considered and confirm that I comply with all the requirements set out therein

I understand that the licence may be suspended or revoked if any of the above statements are false and I understand that I may be liable to prosecution if I have knowingly or recklessly made a false statement or have omitted any material particular from this application.

I declare that neither I nor any partners, nor any of the Directors of the Company (to the best ofmy knowledge) is disqualified from holding a Private Hire Operator’s Licence and/or HackneyCarriage Vehicle Licence.

I willNotify the Council of any changes of operating address, convictions incurred, criminal ordriving, during the period of the licence within 7 days of the conviction or County CourtJudgements i.e. in the case of bankruptcy etc. which affect the licence.

Signed ……………………………………Dated …………………………….……………

Print Name...... Position in Business…………………………………

This authority is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes. To obtain any information held about you please contact the Procurement and Technical Officer on 0115 9173296.

For further information, see

or contact the licensing department:

Broxtowe Borough Council
Licensing Department
Public Protection Division, Chief Executive’s Directorate
Council Offices
Foster Avenue
Beeston
Nottingham NG9 1AB

0115 917 3241