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

Prefix e.g. first floor flat.
House name/number
Street
Village/Area e.g. Scawby, Bottesford, etc.
Town
County
Post code Please input your post code using capitals and include a space between the first and second parts e.g. DN17 5TY.

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? ^*

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? ^*

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? ^*

Yes

If Yes, please give details

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 ^*

Yes

eForms by AchieveForms