Notice of Management Change

*- indicates required field.

Applicant Details

Name of Licensed Premises *

Licensee *

Licence Number *

Address of the Licensed Premises *

Email address *

Contact Phone *

What are you notifying? *

New Certificate Holding Manager

Temporary Manager

Acting Manager

Termination/Cancellation of Manager Appointment

Please note: A copy of this form will be forwarded to the NZ Police

Name of person completing the form *

Position of person completing form *

(Director, Partner, etc.)

I hereby confirm that the information given is correct. *

I understand that this form will also be forwarded to NZ Police. *

Date *