Request to be removed as designated premises supervisor from London Borough of Barking and Dagenham

Step 2 of 3 Submit the application

Please provide your email address, so the licensing authority can let you know if your application has been successful or not.

Email address Confirm email address

Please attach the completed application form below.

Application form

I/we understand it is an offence, liable on conviction to a fine up to level 5 on the standard scale, under section 158 of the licensing act 2003, to make a false statement in or in connection with this application. The London Borough of Barking and Dagenham is committed to protecting your privacy when you use our services. This privacy notice explains how we use information about you and how we protect your privacy. Please follow the link for more information https://www.lbbd.gov.uk/general-privacy-notice

Ticking this box indicates you have read and understood the above declaration

By continuing, you're giving the Cabinet Office permission to pass the information you're supplying to the relevant authority.

For more details on how your information is used please refer to the Government Digital Service privacy notice (opens in new tab) and the London Borough of Barking and Dagenham privacy notice (opens in new tab).