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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 Certicate (July 2014)
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Checklist for
Manager’s Certicate
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 Qualication Certicate (LCQ)
Copy of Training Certicate 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 Ofcer
Code LIQL 3100030316