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PO Box 747, Gisborne 4040 06 8672049 0800 653 800 [email protected] www.gdc.govt.nz
A447673 - FORM 17 Application for Manager’s Certicate (July 2014)
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Checklist for
Manager’s Certicate
Sections 219, Sale and Supply of Alcohol Act 2012
The following must be attached before the application will be accepted for processing
Please tick when completed:
One copy of completed application form
Prescribed Fee (paid)
One reference relating to your experience and current involvement in the alcohol industry
Copy of Licence Controller Qualication Certicate (LCQ)
Copy of Training Certicate showing date of completing Unit Standards 4646 and 16705.
Is the applicant to be appointed as Temporary Manager? Yes No
If yes, a ‘Notice of Management Change’ form must be attached to this application form or submitted within
2 days of lodging this application.
Please ensure all parts of this form are completed as relevant.
OFFICE USE ONLY
Amount $316.25 (GST incl) Scanned Objective No.
Payment Received by GDC / /20 Ofcer
Code LIQL 3100030316
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I don’t pay good wages because I have a lot of money; I have a lot of money because I pay good wages. | Robert Bosch