Licence No..................................

• 1.In exercise of powers conferred upon it by section 19 of the Act, and after considering the application dated .................................. for on-premises use/off-premises use/club use/special use licence, the ................................................................................. Divisional Liquor Licensing Authority hereby grants/renews the licence to .................................. in respect of the premises known as .................................. situated at .................................................................................
• 2.This licence comes into force on the .................................. day of ................. 20.., and remains in force until 31 December 20..
• 3.This licence is issued subject to the Liquor Act 2006 and any Regulations made under the said Act and also subject to the following special conditions—

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• 4.The licence fee is $..................................

Dated this.................................. day of ................. 20..

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Secretary

Divisional Liquor Licensing Authority