Application for a house to house collection licence

Under Section 2 of the 1939 Act

"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 within the authority for the prevention and detection of fraud. It may also share this information with other bodies administering public funds solely for these purposes."

Full name of applicant

Title

If Other, please specify

First name(s) *

Surname *

Address

If the address is within North Lincolnshire, enter the postcode in the box below and then select "find address". If the address is outside of North Lincolnshire, or your address is NOT SHOWN in the list or is incorrect, you will need to enter the address in the boxes provided below.

Postcode

Prefix

e.g. first floor flat

House number/name

Street

Town/village

County

Country

Contact Tel No.

Email address

(Note: on submitting your completed form, if you have provided a valid email address you will automatically receive a copy of your completed form).

Particulars of charitable purposes to which proceeds of collection are to be applied *

Over what part(s) of the North Lincolnshire area is it proposed that the collection should cover? *

Please specify the date(s) required *

Is it proposed to collect money? *

Is it proposed to collect money?

Yes

Approximately, how many persons will be authorised to act as collectors? *

(Please note persons under the age of 16 are NOT allowed to collect)

Is it proposed that remuneration be paid out of the proceeds of the collections? *

Is it proposed that remuneration be paid out of the proceeds of the collections?

Yes

If Yes, please give details

Have you, or anyone associated with the promotion of the collection, been refused a licence or had an order revoked under the Act? *

Have you, or anyone associated with the promotion of the collection, been refused a licence or had an order revoked under the Act?

Yes

If Yes, please give details

I have forwarded a signed letter of authorisation from the Charity to collect on their behalf *

I have forwarded a signed letter of authorisation from the Charity to collect on their behalf

Yes

Letters of authorisation should be sent to the following address:

Licensing Division
North Lincolnshire Council
Church Square House
PO Box 42
Scunthorpe
DN15 6XQ

I hereby apply for a licence to be granted to me under Section 2 of the 1939 Act, in order that I may promote in accordance with the above particulars, which I declare to be true and accurate to the best of my knowledge and belief.

I agree with the above declaration *

I agree with the above declaration

Yes

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