Consent of individual to being specified as premises supervisor

Replace the text in square brackets [ ] with your own information

I, [full name of prospective premises supervisor], of [home address of prospective premises supervisor], confirm that I give my consent to be specified as the designated premises supervisor in relation to the application for [type of application] by [name of applicant] relating to a premises licence [number of existing licence, if any] for [name and address of the premises], and any premises licence to be granted or varied in respect of this application concerning the supply of alcohol at the premises. I also confirm that I am entitled to work in the United Kingdom and am applying for, intend to apply for or currently hold a personal licence, details of which are set out below.
Personal licence number (if any): 
Personal licence issuing authority (if any) name, address and phone number: 

Signed: 
Name (please print): 
Date: