Service Manager Training Certificate
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Details of Applicant Name in full: Surname First Name Middle Name Any other name the applicant is known by: Usual Residential Address: Postal Address: (for service of documents) Sex: Male Female Date of Birth: Place of Birth: Occupation: Phone: Day Mobile Email: Current place of employment: Criminal Offences Has the applicant been convicted of any offence: Yes No What are the details of each offence (refer to notes) Nature of Offence Date of Conviction A447673 - FORM 17 Application for Manager’s Certificate (July 2014) PO Box 747, Gisborne 4040 • 06 8672049 • 0800 653 800 • service gdc.govt.nz • www.gdc.govt.nz Page 2 of 4 Experience and Qualifications Has the applicant has any experience (in particular recent experience) in controlling any premises or conveyance in respect of which a licence was in force Yes No Yes No If yes, what are the details and dates of that experience Date Details Has the applicant had any relevant training, in particular, recent training If yes, what are the details of that training and on what date(s) was it taken Date Details Does the applicant hold the Licence Controller Qualification (or a prescribed qualification within the meaning of section 218 of the Sale and Supply of Alcohol 2012) Yes No Yes No If yes, what date was that qualification obtained Does the applicant intend at this time to be the manager of any particular licensed premises If yes, what are the identifying particulars of those licensed premises If it is a club, what is the extent of the applicant’s involvement in its management and activities Signature Signature of the Applicant Dated at (place) this day of 20 A447673 - FORM 17 Application for Manager’s Certificate (July 2014) PO Box 747, Gisborne 4040 • 06 8672049 • 0800 653 800 • service gdc.govt.nz • www.gdc.govt.nz Page 3 of 4 Notes 1..
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Details of Applicant Name in full: Surname First Name Middle Name Any other name the applicant is known by: Usual Residential Address: Postal Address: (for service of documents) Sex: Male Female Date of Birth: Place of Birth: Occupation: Phone: Day Mobile Email: Current place of employment: Criminal Offences Has the applicant been convicted of any offence: Yes No What are the details of each offence (refer to notes) Nature of Offence Date of Conviction A447673 - FORM 17 Application for Manager’s Certificate (July 2014) PO Box 747, Gisborne 4040 • 06 8672049 • 0800 653 800 • service gdc.govt.nz • www.gdc.govt.nz Page 2 of 4 Experience and Qualifications Has the applicant has any experience (in particular recent experience) in controlling any premises or conveyance in respect of which a licence was in force Yes No Yes No If yes, what are the details and dates of that experience Date Details Has the applicant had any relevant training, in particular, recent training If yes, what are the details of that training and on what date(s) was it taken Date Details Does the applicant hold the Licence Controller Qualification (or a prescribed qualification within the meaning of section 218 of the Sale and Supply of Alcohol 2012) Yes No Yes No If yes, what date was that qualification obtained Does the applicant intend at this time to be the manager of any particular licensed premises If yes, what are the identifying particulars of those licensed premises If it is a club, what is the extent of the applicant’s involvement in its management and activities Signature Signature of the Applicant Dated at (place) this day of 20 A447673 - FORM 17 Application for Manager’s Certificate (July 2014) PO Box 747, Gisborne 4040 • 06 8672049 • 0800 653 800 • service gdc.govt.nz • www.gdc.govt.nz Page 3 of 4 Notes 1..
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