Licensing (Jersey) Law 1974 Self-declaration Form (Dec 2016) Instructions

Enter your full residential address including house number or name, street, and any apartment or unit details.

Enter the name of the Jersey parish where you currently reside.

Enter the full postal code for your address, including any letters, numbers and spacing.

Enter your primary telephone number for contact, including country and area code if applicable.

Enter your primary email address that you wish to be used for correspondence.

Enter the applicant's full name followed by the first line of their current residential address (e.g., house number/name and street).

Enter the applicant's family name or last name exactly as shown on official identification.

Enter the applicant's title (for example Mr, Mrs, Miss, Ms, Dr or other courtesy title).

Enter the applicant's given name(s) in full as shown on official identification, including all middle names if applicable.

Enter the applicant's date of birth.

Enter the town or city (and country if required) where the applicant was born.

Enter the reference or licence number for the licence that this application relates to.

Check this box if the application is for a licence for the premises (i.e., you are applying to be granted the licence).

Enter the full name of the manager or deputy manager of the licensed premises to which this application relates.

Check this box if the application is for registration as a manager or deputy manager of the licensed premises (rather than for the licence itself).

Check this box if you have ever been convicted of any offence (including offences committed in a foreign country) and will provide details of each offence as required.

Check this box if you have never been convicted of any offence (including offences committed in a foreign country).

Enter either 'Yes' or 'No' to indicate whether you have ever been convicted of any offence (including offences committed in a foreign country). Fill only if 'Question 6: Yes' is 'Yes'.

Provide full details of each conviction including the date of conviction, the convicting court, the offence for which you were convicted, and the sentence imposed (include spent convictions as required). Fill only if 'Question 6: Yes' is 'Yes'.

Enter your acknowledgement or brief confirmation related to the Data Protection notice (for example your initials, ‘I agree’, or any required short statement confirming you have read and understood the Data Protection notice).

Enter a short confirmation that you accept the declaration in Section 8 (for example your initials, 'I confirm', or other required acknowledgement as instructed).

Enter the applicant's full name as their signature to confirm that the information on the form is correct.

Enter the date on which the applicant signed the declaration.

Enter 'Yes' to confirm you have been resident in Jersey for the entire 3 years immediately preceding the application date.

Enter 'No' to indicate you have not been resident in Jersey for the entire 3 years immediately preceding the application date (if 'No', provide details of where you lived during that period in the subsequent address fields).

Enter the licence reference, number or brief identifying details of the licence to which this application relates.

Enter the full name of the licensed premises to which this application relates.

Check this box if you hold licence category 1.

Check this box if you hold licence category 3.

Check this box if you hold licence category 5.

Check this box if you hold licence category 6.

Check this box if you hold licence category 7.

Check this box if you hold licence category 2.

Check this box if you hold licence category 4.

Enter the parish hall contact information for the Connétable or parish (e.g., name, full postal address, telephone number and email) as applicable.

Check this box if you have attended a Parish Hall Inquiry (Question 7) and will provide details of each attendance below.

Check this box if you have never attended a Parish Hall Inquiry (Question 7) and therefore have no attendance details to provide.

Enter the number of Parish Hall Inquiries you have attended (provide a numeric count as text). Fill only if '7. Attended a Parish Hall Inquiry – Yes' is 'Yes'.

Provide the full details for each attendance including the date of attendance, the parish you attended, and the reason for your attendance; include one or more entries as needed. Fill only if '7. Attended a Parish Hall Inquiry – Yes' is 'Yes'.

Enter the decision or outcome recorded by the Centenier for the attendance(s) listed. Fill only if '7. Attended a Parish Hall Inquiry – Yes' is 'Yes'.

Enter 'Nil' in this box if you have no previous addresses in the last 5 years; otherwise leave it blank.

Enter the primary street address or first line (house number/name and street) for a previous residence within the last 5 years. Fill only if 'Previous Addresses - Nil/None indicator' is not 'Nil'.

Enter the full address details (additional address lines, town/parish and postcode) or list further previous addresses within the last 5 years in this multiline area. Fill only if 'Previous Addresses - Nil/None indicator' is not 'Nil'.

Enter the date or date range when you lived at the address provided alongside this field. Fill only if 'Previous Addresses - Nil/None indicator' is not 'Nil'.

Enter the word 'Nil' in this box if you have no previous names (including maiden name); otherwise leave blank or use the fields below to list your previous names.

List any former surnames you have used (include maiden name), separated by commas if there are multiple, or enter 'Nil' if none. Fill only if 'Previous names (enter 'Nil' if none)' is not 'Nil'.

List any former forenames (first and middle names) you have used, separated by commas if there are multiple, or enter 'Nil' if none. Fill only if 'Previous names (enter 'Nil' if none)' is not 'Nil'.

Provide the date or dates on which each name change occurred, or leave blank if you have not changed your name. Fill only if 'Previous names (enter 'Nil' if none)' is not 'Nil'.