Notice of Management Change
Section 231, Sale and Supply of Alcohol Act 2012

Name of Licensed Premises:	
Licensee:	Licence Number:	
Address of Licensed Premises:	
Contact Phone: (	)	Contact Fax: ( ______ )	

What are you notifying? (Please tick and complete the applicable box below)
 New Certificate Holding Manager
Full Name 	Effective from:	/	/ 2 0	
Certificate Number:	Certificate Expiry Date:	

 Temporary Manager 
Effective from:	/	/ 2 0	to	/	/ 2 0	
Full Name:	Date of Birth:	
Residential Address:	
Who they are replacing:	Certificate Number:	
Reason:	
Note that a Temporary Manager, must apply for a Manager's Certificate within two working days of 
their appointment

 Acting Manager 
Effective from:	/	/ 2 0	to	/	/ 2 0	
Full Name:	Date of Birth: 	
Residential Address:	
Who they are replacing;	Certificate Number:	
Reason:	
 Termination/Cancellation of Manager Appointment
Full Name:	Effective from:	/	/ 2 0	
Certificate Number:	Certificate Expiry Date:	

Forward a copy of this completed form to:
Your Local District Licensing Committee:   	Fax No.	
Your Local Police:	Fax No.	

Signature of licensee:	Date:	
Name:	Position (director, partner etc.):	 
Notes: Use this form for the appointment of a Temporary Manager, Acting Manager, newly appointed Manager or termination of a Manager.  You do not need to fax this form or make an application for a Manager’s Certificate if the appointment is for less than 48Hours.  This is a form accepted by the Alcohol Regulatory and Licensing Authority, provided for your use by WA Consulting Group Ltd.  Liquor Licensing Consultants. PO Box 2028, Rotorua 3040, Phone 07 348 0630