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To the North East Lincolnshire Council, the Licensing Authority for Great Grimsby, Cleethorpes, Immingham and surrounding areas.

Form of application for permission to collect money or sell articles in streets or public places within the district of North East Lincolnshire for the benefit of charitable or other purposes.

Particulars of Collection

1. Details of person, society, committee or other body of persons responsible for the collection or sale:

Please use Add button if need to list more than one

Title

Mrs

Miss

Other

If 'Other' please specify

First Name

Surname

Or, Name of Society

Or, Name of Committee

Or, Name of Other Body of Persons

2. Address Line 1

Address Line 2

Address Line 3

Postcode

Email Address

Please use Add button if need to list more than one

3. Please give name(s) and address(es) of the applicant(s) for the permit who will be (jointly) responsible for the collection or sale:

Title

Mrs

Miss

Other

If 'Other' please specify

First Name

Surname

Or, Name of Society

Or, Name of Committee

Or, Name of Body of Persons

Address Line 1

Address Line 2

Address Line 3

Postcode

4. Details of Charity or Fund which is to benefit

Name of Charity

Charity Number

5. Details of Administrative Centre of the Fund and the name of the secretary:

Title

Mrs

Miss

Other

If 'Other' please specify

First Name

Surname

Address Line 1

Address Line 2

Address Line 3

Postcode

Telephone Number

Email Address

6. Object of the Charity or Fund

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North East Lincolnshire Council, Municipal Offices, Town Hall Square, Grimsby, DN31 1HU, (01472) 313131

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