MID DEVON DISTRICT COUNCIL

                                      ENVIRONMENTAL HEALTH SERVICES

                                        PHOENIX HOUSE, PHOENIX LANE

                                              TIVERTON, DEVON EX16 6PP

 

 

APPLICATION FOR A STREET COLLECTION PERMIT

 

In Pursuance of the Police, Factories etc. (Miscellaneous Provisions) Act 1916

In Pursuance of the Charities Act 1992 and the Charitable Institutions (Fund-Raising Regulations 1994)

 

 

APPLICANT (This is the person jointly responsible for the collection or sale)

 

1.    Title: Mr/Mrs/Miss/Ms/Other   Surname 

 

       Other Names                      

 

2.    Full Postal Address 

      

      

 

Post Code      Daytime Telephone Number 

 

        

 

3.     Date and Place of Birth 

 

4.     Name and Address of Society, Committee or Body responsible for the conduct of this collection 

       

       

         (a)  Are you a member of the above Society?       YES            NO

 

         (b)  If yes, please state your position 

 

IF NO, YOU MUST SUPPLY, IN WRITING, AUTHORISATION FROM THEM TO COLLECT ON THEIR BEHALF

       (if you have this in electronic format you will be able to upload it when submitting the form)

5.    Name and Address of the Charity or Fund which is to benefit 

     

      

      

 

6.    Please state the objectives of the Charity or Fund 

     

      

7.    (a) Is the Charity Registered with the Charity Commission?        YES            NO

 

       (b)  If yes, please state Registration Number  

 

8.    On what Date(s) is it proposed to collect?      

 

9.    Between what Hours is it proposed to collect? 

 

10.  In which Areas/Towns is it proposed to collect? 

      

      

 

11.  By what method will the collection or sale be made?  (e.g. in sealed tins, or other receptacles) 

      

      

 

 

12.    What arrangements are proposed to ensure that the proceeds of the collection are handed over with the least possible delay to the person responsible for the proper application of the money? 

     

      

 

      

      

13.  Is it proposed that the whole of the proceeds shall be paid over to the Charity/Fund?   YES     NO

 

 

       If NO, please state the approximate amount and the purpose for the deductions 

      

      

 

       PLEASE NOTE THAT NO DEDUCTIONS CAN BE MADE UNLESS DETAILS ARE STATED ON THIS FORM

 

14.   Is application being made for Collection Permits, for the same purposes, in other Local Authority areas?


YES   NO              
If YES, please state ALL authorities applied to 

 

 

 

15.  Approximately how many persons is it proposed to act as collectors in this Authority’s area? 

 

16     Have you, or to your knowledge anyone associated with the promotion of any Collection, been refused a Permit  under the Act, or ever had a Permit revoked?  

  YES       NO          
   If YES, please give full details  
   


17.  Have you previously been granted a Street Collection Permit by this Authority?  YES     NO

 

       If YES, please indicate the date of the last collection and Permit number (if known) 

  

 

18.  Is it proposed to collect the collection in conjunction with a House to House Collection?  YES     NO

 

       If YES, please state whether the House to House collection will be conducted under:

 

       (a)   A Home Office Exemption Order 

 

(b)      A Licence:          which has already been issued 
 or which an application has been or is to be made 

 

       (c)  Give dates of any proposed House to House collection 

 

I hereby apply for a Permit authorising me to conduct a public charitable collection, the particulars of which are aforementioned, and which are true to the best of my knowledge and belief, the collectors to be employed are aged 18 or over and are fit and proper persons for the purposes of the collection specified.

 

I undertake to provide to the local authority, within 4 weeks of the last date on which a collection takes place, a statement of income and expenditure (as required by Mid Devon District Council) using the Authority’s prescribed form for this purpose, a copy of which will be provided at the same time as the issue of any Permit.

 

I hereby authorise the Local Authority to make such checks as they consider prudent concerning this application and also to consult with the Police, the Charity Commission and other public agencies if necessary and in pursuance of such enquiries are authorised to disclose any information given herein.

 

WARNING:  Any person who, for the purpose of an application under the Police, Factories (Miscellaneous Provisions) Act 1916, knowingly or recklessly furnishes any information which is a false in a material particular, shall be guilty of an offence.

 

 

Name:     Dated: 

 

Human Check:

Please return form to: MID DEVON DISTRICT COUNCIL,ENVIRONMENTAL HEALTH SERVICE,   PHOENIX HOUSE, PHOENIX LANE, TIVERTON, DEVON EX16 6PP

Tel: 01884 255255 Fax: 01884 234256