APPLICATION FOR A LICENCE TO CONDUCT
A PUBLIC CHARITABLE COLLECTION		
Police, Factories, etc [Miscellaneous Provisions] Act 1916
Section 2 of House to House Collections Act 1939

Please return completed form to: 
Licensing, Bromsgrove District Council, Parkside, Market Street, Bromsgrove, Worcestershire, B61 8DA
APPLICANT	
SURNAME: 		
OTHER NAMES:		
FULL POSTAL ADDRESS:		
POST CODE		
TEL NO:
(for contact during office hours)		
PLACE AND DATE OF BIRTH		
DO YOU REPRESENT A COMPANY?	YES/NO
Company House Reg No:	

CHARITY,ORGANISATION OR PERSON TO BENEFIT:	
NAME:		
ADDRESS:		
IS THE BENEFICIARY A REGISTERED CHARITY?	YES/NO
Reg Charity No:	
IS THE BENEFICIARY AN ORGANISATION OR INDIVIDUAL?	ORGANISATION/ INDIVIDUAL (Delete as applicable)	

PROPOSED COLLECTION DETAILS AND PURPOSE:	
ARE YOU APPLYING FOR A LICENCE TO COLLECT:	1.	IN THE STREET?			
	2.	HOUSE TO HOUSE?		
WILL IT FORM PART OF A PROCESSION?		YES/NO	
COLLECTION DATES REQUSTED:
(IN ORDER OF PREFERENCE)	1.	
	2.	
	3.	
WHERE DO YOU WISH TO COLLECT IN the jurisdiction of Bromsgrove District Council? (attach a map if necessary)		

IS IT PROPOSED TO COLLECT MONEY?	YES/NO	IS IT PROPOSED TO COLLECT ARTICLES?	YES/NO	
IS IT PROPOSED TO SELL ARTICLES?	YES/NO	PRICE OF ARTICLES FOR SALE: £	
DESCRIPTION OF ARTICLES OFFERED OR EXPOSED FOR SALE:		
PURPOSE OF COLLECTION:	

ALLOCATION OF PROCEEDS:	
WILL THE WHOLE OF THE COLLECTION (100%) BEAPPLIED FOR THE BENEFICIARY?	YES/NO	
IF NO, STATE IN GENERAL TERMS THE AMOUNTS (GROSS) TO BE APPLIED OUT OF EACH £1 FOR:	a) WAGES/COMMISSION		
	b) FUND-RAISING EXPENSES		
	c) CHARITABLE PURPOSE		

PAYING-IN DETAILS:	
MONEY COLLECTED WILL BE PAID INTO THE FOLLOWING ACCOUNT:	
ACCOUNT HOLDER NAME:	BANK NAME & ADDRESS	
ACCOUNT NO:	SORT CODE:	

CERTIFICATION OF ACCOUNTS	
NAME & ADDRESS OF PERSON WHO WILL CERTIFIY FINAL ACCOUNTS:
	
QUALIFICATIONS:	

CONVICITONS OR REFUSAL OF LICENCES:	
Have you or, to your knowledge, anyone connected with this proposed collection been refused a licence in respect of any collection for charitable, benevolent or philanthropic purposes, or had a licence/permit refused or revoked; or has anyone connected with the proposed collection or organisation making this application been convicted of offences of dishonesty?	
YES/NO	
ADDITIONAL INFORMATION (if applicable):
(Attach a separate sheet if necessary.)	

DECLARATION:	
I undertake to provide Bromsgrove District Council, within 4 weeks of the collection taking place, a certified statement of income and expenditure using the Council’s prescribed form for this purpose.  I understand the net total of the collection proceeds, as declared on the certified statement, will be supported by either a copy of the paying-in-slip(s) which have been stamped and initialled by the bank cashier, or a signed statement by the bank certifying the total monies paid in.  Such a signed statement must also bear the bank’s dated stamp.
I hereby authorise the Council to make such checks as they consider necessary to verify the information given above and give my consent to such checks being made with the Police, other Authorities or the Charity Commission for this purpose.
I certify that all material facts herein are true.	
Signature of applicant:		Date:		

Please enclose with your application the following documents as applicable:
1.	A copy of any agreement or particulars of any contract with any Registered Charity, organisation or individual benefiting from this collection.
2.	A copy of the current published accounts for any Registered Charity and/or any Registered Company undertaking, or involved with this collection.
3.	Copies of any literature about organisations or individuals who will benefit.
4.	The written agreement of the manager of the land, if collecting on private land.