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West Somerset Council

Collections Licence (Charitable Purposes) Application

Fields marked with * must be completed
Applicants Name *:
Name of Charitable Organisation *:
House Number/Name *:
Street Name *:
Town/Area *:
Postcode *:
Telephone Number *:
Email Address:
Position in Charity/Organisation:
Name of charity to which proceeds of collection will be applied *:
Charity Registration Number *:
Is the charity in receipt of an Exemption Certificate? (if yes, a copy will need to be supplied) *:	Yes No
Companies House Number (if applicable):
Description of charity if not registered with Charity Commission (max 800 characters):
Part(s) of the district to be covered by collection *:
Type of Licence *:	Street House to House
Date of proposed collection *:	Date and time
Alternative date:	Date and time
Start and finish times of street collection (if applicable):
Number of persons to act as collectors *:
Is application being made for licences in other districts? If yes, state which (max 800 characters):
Will the collection involve...
The collection of money *:	Yes No
The use of direct debits/standing orders *:	Yes No
The collection of articles *:	Yes No
If yes, list type of items involved and what will happen to them (max 800 characters):
The sale of articles *:	Yes No
If yes, list type of items involved and their price(s) (max 800 characters):
Will the collections be taken as part of an event or in the course of performance? *:	Yes No
If yes, give details (max 800 characters):
Will the whole proceeds of the collection(s) be paid to the charity? *:	Yes No
If no, state the percentage that will go to the charity; wages/commission; expenses; other (please give details), giving the approximate percentage (max 800 characters):
Have your or, to your knowledge, anyone connected with this proposed collection, previously been refused a licence in respect of any collection for charitable, benevolent or philanthropic purposes, or had a licence/permit refused or revoked? *:	Yes No
If yes, give reason (max 800 characters):
Declaration
I confirm that the information supplied is true and complete to the best of my knowledge.
Tick box to agree *:
Security Code *:

Your form will be received by our Customer Services Team who will deal with your enquiry or forward to the relevant department for action.