Request to be removed as designated premises supervisor from Islington Council

Step 2 of 3 Submit the application

Please provide your email address, so the licensing authority can let you know if your application has been successful or not.

Email address Confirm email address

Please attach the completed application form below.

Application form

IT IS AN OFFENCE, UNDER SECTION 158 OF THE LICENSING ACT 2003, TO MAKE A FALSE STATEMENT IN OR IN CONNECTION WITH THIS APPLICATION. THOSE WHO MAKE A FALSE STATEMENT MAY BE LIABLE ON SUMMARY CONVICTION TO A FINE OF ANY AMOUNT.
I HEREBY CONFIRM THAT I SENT A COPY OF THIS NOTICE AND DIRECTION TO THE PREMISES LICENCE HOLDER AT THE ADDRESS SHOWN ON

Ticking this box indicates you have read and understood the above declaration

By continuing, you're giving the Cabinet Office permission to pass the information you're supplying to the relevant authority.

For more details on how your information is used please refer to the Government Digital Service privacy notice (opens in new tab) and the Islington Council privacy notice (opens in new tab).