Appendix 1 - Application
Perth and Kinross Council · 29 May 2023
Back to Licensing Committee — 29 May 2023 and its agenda
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E 0305; For Official use on S .m,. Date 3 l}401l received S NZ Receipt g PERTH & 1034 W030f 3 REQUEST FOR CONSENT TO MATERIAL CHANGE E IN CIRCUMSTANCES OR ALTERATION OF CIVIC GOVERNMENT (SCOTLAND) ACT, 1982 LICENCE TAXIIPRIVATE HIRE DRIVER, TAXI OPERATOR, PRIVATE HIRE OPERATOR LICENCE 4 PLEASE COMPLETE IN BLOCK CAPITALS holder details Licence holder name 012$ KnTHLeeN D\I K9 Licence holder LS1 mU030z}402lMceezm030r address cm030mg_ ' . m ouw Contact telephone "umber Email address Question 2 024Licence Details Type of Licence held TaxilPrivate Hire Driver D Taxi Operator El Private Hire Operator '3' pH Q13
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E .. . . _. Z Question 3 - 2 Variation Details E Do you wish to remove § someone from your Yes El No 2031N/a [I : licence? _ w If034yes031,please provide full details ofthe person to be moved. Do__you wish to add someoneto your ' Yes D No IZI Na El licence? 030 ' _ if034yes035,please pmvide . fultwdetailsofthe _ person to he added. --024 Private Homé Addfess (inciuding postcode , ~ __ Date: and pIaoe031of_ Years Date of Birth Place of Birth birth A . , 030
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m 3 3? Does helshe have an E OOIWiC}401Q}402S y Yes D No D i g , m W5 Convictions (Please - ' - use separate sheet if necessary) Has the new persoh (if applicable) lived in the UK for at least 10 Yes D No [:1 years? if no, please provide a letter from your home country continuing that you do not have any convictions. _ Do you have a change if} your medical ' Yes D No lg] Na El history? 031 if 034yes035pieaseprovide detaiia 0f your medical Date }401rstdiagnosed - -/- -/- - - - condition. _ 030 Condition Are your receiving any medicationlmedical attention in connection with this condition? Yes [:I No [I Describe the effect this may have on your }401tnessto drive a Taxi/Private Hire car 030 Do you have any medical condition which would prevent you carrying a guide dog or assistance dog in your vehicle? I Yes [I No [I
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3: Are you informing the Lunsing : Department of criminal Yes [:1 No M Na El 3 convictions andlor driving E offences? E L Type of criminal conviction 024 P Sentence 024______ E Driving Offence Points obtained Are you applying to display . advertisementls on your vehicle? Yes [:1 N0 E Na El , , Attach a design proof of the advertising cleany showing where the advertising will be placed on the vehicle. Please con}401rmthat you are displaying 034PreBook Hire035signs? Yes D No El Are' there any other changes that aro not hated above that you wxsh Yes [3 No D to make. N<e4m3 47) extend use qf Van sows aw , as W Please give as much information I l \ . t . . to the change you wish to make. a a new 034WACb030»M 3 3 M3 untd Oc+ubcr 4hr. am:- Home WA order 030Qrmas ?c ' _ , 0% Hus- 6. CHECKLIST a Have an endosedlmade ment of the £71.00 law W -~m (b) 030Haveyou enclosed a design proof of the advenising you wish on yourvehicle Yes E] 034ME (c) If the personis who I have added to my license has not tived in the ,UK for 10 years I have Yes D NA IZf enclosed a letter from their home country con}401rmingthat Ilmy manager have/have not got any convictions
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§ 3 0300 .5; g E HOW WE USE YOUR PERSONAL INFORMATION \ E The information provided by you will be used by Perth & Kinross Council to process your application and ; thereafter to keep you informed of any updates with regard to your application or licence. Q Your information will be shared with Police Scotland, Scottish Fire and Rescue Service, Planning Service and Environment Services in order to determine if you are a }401tand proper person to hold a licence. A requirement for this licence is to display a site notice for 21 days which the public can view and this will contain personal information which will include your name and address. The Council may also check information provided by you, or information about you provided by a third party, with other information held by us. We may also get information from certain third parties or share your information with them in order to verify its accuracy, prevent or detect crime, protect public funds or where required by law. Further information on how your information is used can be found here httgs:[(www.pkc.gov.uk[detailedprivagnotices You should be aware that the names of individuals who hold this licence appear on a register which is available for public inspectionzyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA I declare that the particulars given by me on this form are true. I consent to the sharing of my personal information for the purposes set out above. Signature of applicantlagent Date 39031319056 Signature of applicant(s) to be removed from licence or added to licence Date It is an offence to make any statement in this application which you know to be false or to recklessly make any statement which is false in a material particular. Offences are punishable by a fine up to £1,000. June 2019