Application Form:

Applicant Surname:

Applicant First Names:

Home Address:

Home Postcode:

Mobile Number:

Email Address:

Date of Birth:

National Insurance Number:

Do you have any unspent convictions that may be relevant to the proposed licence holder’s fitness to hold a licence and, in particular, any such conviction in respect of any offence involving fraud or other dishonesty, or violence or drugs or any offence listed in Schedule 3 to the Sexual Offences Act 2003(a)?
YesNo

Has there been any finding by a court or tribunal against the proposed licence holder that they have practised unlawful discrimination on grounds of sex, colour, race, ethnic or national origin or disability in, or in connection with, the carrying on of any business?
YesNo

Has there been any contravention on the part of the proposed licence holder of any provision of any
enactment relating to housing, public health, environmental health or landlord and tenant law which led to civil or criminal proceedings resulting in a judgement being made against you?
YesNo

Do you have any information about any HMO or house the proposed licence holder owns or manages or has owned or managed which has been the subject of either a control order under Section 379 of the Housing Act 1985(a) in the five years preceding the date of the application or any appropriate enforcement Act.?
YesNo

Do you have any information about any HMO or house the proposed licence holder owns or manages or
has owned or managed for which a local housing authority has refused to grant a licence under Part 2 or 3 of the Act, or has revoked a licence in consequence of the licence holder breaching the conditions of his licence?
YesNo

Do you have any information about any HMO or house the proposed licence holder owns or manages or has owned or managed that has been the subject of an interim or final management order under the Act?

YesNo

Has any local authority carried out work in default to premises of which you have been the owner in the past 5 years
YesNo

Has the licence holder been declared bankrupt?
YesNo

Have you ever had any application for a HMO/Property licence refused, revoked or Management Orders imposed, in this or another local authorities area?
YesNo

10) Please Upload your Photo ID (e.g. Passport / Driving Licence) and also a recent Utility Bill or bank statement for proof of address

Information regarding the property ownership:

Licensed Property Address:

Licensed Property Postcode:

How many storeys does the property have?:

Do you own the freehold of the property
YesNo

If you do not hold the freehold of the property is there at least 5 years still left to run on the lease
YesNo

Is there a mortgage on this property?
YesNo

Is this property currently tenanted?
YesNo

Select Property type
detached houseterrace houseend terrace housesemi-detached houseflatOther

Select approximate age of the original construction of the property
Before 19191919-19441945-19641965-1979After 1980Not Sure

How many floors does the property have?

Number of individual tenants at the time of application:

Number of people living in the property:

Total number of households occupying the property:

Of those number of children living in the property (age 11-17):

10 years or under:

Total number of habitable rooms (except kitchens):

Total number of bedrooms:

Total number of livingrooms:

Total number of bathrooms/shower rooms:

Total number of toilets with wash hand basins:

Total number of toilets without wash hand basins:

Total number of wash hand basins:

Total number of kitchens:

Total number of sinks:

Smoke and heat detectors?
YesNo

Does the property have an electrical cert?
YesNo

Do you provide gas safety certificate to any part of the property?
YesNo

What EPC rating is your property?
ABCDEFG

Attach EPC Certificate