Notice of Management Change

*- indicates required field.

Section 231, Sale and Supply of Alcohol Act 2012

Applicant Details

Name of Licensed Premises *

Licensee *

Licence Number *

Address of the Licensed Premises *

Can't find your address? CLICK HERE to Enter it manually

Email address *

Contact Phone *

What are you notifying? *

New Certificate Holding Manager

Temporary Manager

Acting Manager

Termination/Cancellation of Manager Appointment

Please note: You MUST send a copy of this form to your nearest Police Station within two days of appointment/Termination (a copy will be emailed to you after submission, forward email to NZ Police)

• Te Awamutu & Cambridge - teawamutu@police.govt.nz
• Hamilton - Hamilton.DLU@police.govt.nz

Are you the licensee? *

Yes

Position of person completing form *

I hereby confirm that the information given is correct. *

I confirm that I will forward a copy of this form to NZ Police. *

Date *