Consent of individual to being specified as premises supervisor Full name of prospective premises supervisor Required Address of prospective premises supervisor Required Postcode Lookup Telephone number Required Email Address Required Hereby confirm that I give my consent to be specified as the designated premises supervisor in relation to the application for a vary a premises licence to specify an individual as designated premises supervisor. Consent: Required Yes Name of licence holder Required Relating to a premises licence Premise licence Number, if any Name of premise Address of premise Postcode Lookup Name of licence holder Concerning the supply of alcohol at Name of premise Address of premise Postcode Lookup