Premises licence holder(s) Details I/we, full name of premises licence holder(s) Required The premises licence holder of premises licence number Required Name and address of premises to which the application relates Required Email address of the premise licence holder Required Telephone number of the premise licence holder Required Hereby give my consent for the transfer of premises licence number Required [insert premises licence number] Full name of transferee Required It is an offence, under Section 158 of the Licensing Act 2003, to make a false statement in or in connection with this application. Those who make a false statement may be liable on summary conviction to a fine of any amount.