• 1.Full Name (including any aliases) and address of applicant: ................................................................................. ................................................................................. .................................................................................
• 2.Date of Birth: .................................................................................
• 3.Phone: .................................. Fax:..................................
• 4.E-mail:.................................. Website:..................................
• 5.Occupation:.................................................................................
• 6.Length of time resident in Fiji.................................................................................
• 7.Marital Status:.................................................................................
• 8.Name and occupation of husband/wife/de facto:.................................................................................
• 9.If licence granted does licensee intend to follow another trade or profession: YES/NO
• 10.Has proposed licensee had experience in the conduct of licensed premises? YES/NO
• 11.If so, provide details:.................................................................................
• 12.Will the proposed licensee have a financial interest in the business? YES/NO
• 13.Is the proposed licensee directly or indirectly interested in or concerned with any other licence? YES/NO
• 14.If so, provide details:.................................................................................
• 15.Has the proposed licensee ever been dismissed/discharged or asked to resign by any employer? If so, provide details: .................................................................................
• 16.Name and address of nominee (if applicable).................................................................................
• 17.Address/location of proposed licensed premises.................................................................................
• 18.Postal address of applicant.................................................................................
• 19.Trading name of proposed licensed premises.................................................................................
• 20.Nature of business associated with licence applied for (eg hotel, supermarket etc) .................................................................................
  • TYPE OF LICENCE APPLIED FOR(TICK APPLICABLE)
  • ON PREMISES USE
  • OFF PREMISES USE
  • CLUB USE
  • SPECIAL USE
• 21.Proposed conditions sought or volunteered by the licensee .................................................................................
• 22.Will any other person or entity have a financial interest in the Business?

  If so, provide details .................................................................................

• 23.Is the applicant directly or indirectly interested in or concerned with any other liquor licence? YES/NO. If so, provide details .................................................................................
• 24.Has the applicant ever been convicted for an offence or has been charged and case is pending in court? Except for irrelevant convictions under Rehabilitation of Offenders (Irrelevant Convictions) Act 1997? YES/NO .................................................................................
• 25.Has the applicant ever been a defendant in a civil lawsuit for breach of duty of care? YES/NO. If so, provide details.................................................................................
• 26.Has the applicant ever been the subject of any action pursuant to the provisions of the Bankruptcy legislation? YES/NO. If so, provide details .................................................................................

  .................................................................................

  .................................................................................

  I,................................................................ the applicant described above, hereby apply for the grant of the above licence.

Signature of applicant..................................

Date................................................................

FOR OFFICIAL USE ONLY

• 1.Date application received.................................................................................
• 2.Fee paid. Revenue Receipt No..................................for $.................................................................................
• 3.Date acknowledgement sent to the applicant: .................................................................................
• 4.Date copies of application sent to respective agencies under section 27 of the Act.................................................................................

  .................................................................................