IN TERMS OF SECTION 37 OF THE MPUMALANGA LIQUOR LICENCING ACT, 2006
| 1 | Name of the Licence Holder | |
|---|---|---|
| 2 | Licence Number | |
| 3 | New Trading Name of the Business, if changed from the existing licence certificate | |
| 4 | Telephone Number | |
| 5 | Mobile Number | |
| 6 | E-Mail Address |
| 7 | Shopping Complex or Mall | |
|---|---|---|
| 8 | Shop Number | |
| 9 | Street Number and Street Name | |
| 10 | Farm or Plot | |
| 11 | Stand Number | |
| 12 | Village, Extension or Suburb | |
| 13 | Area / Town | |
| 14 | Local Municipality | |
| 15 | GPS Coordinates |
| 16 | Description of Alteration(s) Requested | |
|---|---|---|
| 17 | Will the intended alteration change the outside walls or roofed area of the licensed premises? (Yes/No) | |
| 18 | Will the intended alteration ONLY change the inside of the licensed premises? (Yes/No) | |
| 19 | Will the intended alteration change the shop number or building within the same address of the licensed premises? (Yes/No) |
| 20 | Proof of Payment | |
|---|---|---|
| 21 | Signature | |
| 22 | Designation / Job Title of signatory in question 24 (if not the Licence Holder) |