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Being the applicant for the issue of a liquor licence/appointment as nominee as provided by the Airports Control of On-Airport Activities Regulations 1997 (as amended), do solemnly and sincerely declare that:
PERMANENT RESIDENTIAL ADDRESSES OVER LAST FIVE YEARS
PREVIOUS LIQUOR LICENCES HELD
OTHER RELEVANT WORKING EXPERIENCES ON LICENSED PREMISES
I make this solemn declaration by virtue of the Statutory Declarations Act 1959 as amended and subject to the penalties provided by the Act for the making of false statements in statutory declarations, conscientiously believing the statements contained in this declaration to be true in every particular.
Signature and title of person before whom the declaration is made
(Commissioner for Declarations Justice of the Peace or a Public Servant of 5 years standing)
Note: A person who wilfully makes a false statement in a statutory declaration under the Statutory Declarations Act 1959 as amended is guilty of an offence against that Act, the punishment of which is a fine not exceeding $200 or imprisonment for a term not exceeding 6 months or both if the offence is prosecuted summarily, or imprisonment for a term not exceeding four years if the offence is prosecu/infopages/LiquorGuidelines.htm">Click here to see background information relevant to this form.