Preview Service Manager Training Certificate

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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