________________ _____LIQUOR ACT 27 OF 1989__________________

FORM 1
[Reg.3(1)]
Date stamp of
Magistrate receiving
application.
Amount R …….……………….
Receipt No …………………….
Date ……………………………

LIQUOR ACT, 1989

APPLICATION IN TERMS OF SECTION 19 OF A LICENSE

INDEX

Description of document

Annexure

(i) Application …………………………………………………………………………… Form 1

(ii) Plan of the premises [Reg. 3 (2) (a)] ……………………………………………….... A
(iii) Description or photos of the premises [Reg. 3 (2) (b)] …………………………….. B
(iv) Comprehensive written representations [Reg. 3 (2) (c)] …………………………... C
(v) Documents required to be attached to application [Reg. 3 (2) (d)] ……………….. D
(vi) ………………………………………………………………………………………….
(vii) ………………………………………………………………………………………….

Application prepared by ……………………………………………………………………………………..

Postal Address ………………………………………………………………………………………………..

Telephone No …………………………………………………………………………………………………

1. (a) Full name of applicant ………………………………………………………………………………

(b) Age …………………………………………………………………………………………………...
(c) Identity number or in the case of a company or close corporation, its registration number ….
……………………………………………………………………………………………………………
(d) Residential address or address of registered office ………………………………………………
(e) Business address ……………………………………………………………………………………
(f) Postal address ……………………………………………………………………………………….
(g) Business telephone number ………………………………………………………………………..
[Delete (b) if applicant is not a natural person]

2. (a) Is applicant a person who-

(i) has in the Republic or elsewhere in the preceding 10 years been sentenced for
any offence to imprisonment without the option of a fine ……….. Yes No
(ii) has in the preceding 10 years been convicted of an offence in terms of the Liquor
Act, 1989 (Act No. 27 of 1989) or the Liquor Act, 1977 (Act No. 87 of 1977),
irrespective of the sentence imposed, and was within 5 years after the conviction
again convicted of an offence in terms of any of the above-mentioned two Acts
 and was then sentenced therefor to a fine of not less than R200 or to
imprisonment without the option of a fine?..................................... Yes No
(iii) is not domiciled in the Republic? …………………………………. Yes No
(iv) is an unrehabilitated insolvent? …………………………………... Yes No
(v) is a minor? …………………………………………………………. Yes No
(vi) is the spouse of a person contemplated in subparagraphs
(i), (ii) or (iv)? ……………………………………………………… Yes No
(Mark the applicable square)

(b) If the applicant is a company, close corporation, partnership or trust, state whether a person
contemplated in subparagraph (a)-

(h) has a controlling interest in such a company, close corporation or trust ………………. Yes No

(ii) is a partner in such a partnership ………………………………………………………… Yes No

(iii) is the main beneficiary under such a trust ……………………………………………… Yes No

(Mark the applicable square)

(c) If any of the questions in subparagraphs (a) or (b) have been replied to in the affirmative, provide full
details …………………………………………………………………………………………… Yes No

(Use an annexure if necessary)

3. (a) State the name, identify number and address of each person, including the applicant, who will
have any financial interest in the business and in each case the nature and extend of such interest.
[If the applicant is public company, statutory institution or a cooperative as contemplated in the
Co-operatives Act, 1981 (Act No. 91 of 1981), it shall be sufficient if only the name and postal
address of such company, statutory institution or co-operative, as the case may be, the name of
each director (if any) thereof and the nature and extent of the financial interest of such company,
statutory institution or co-operative are furnished and not also the interest of individual
members of such company, statutory institution or co-operative] ………………………………….
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
(Use an annexure if necessary)

(b) State the financial interest in the liquor trade in the Republic of the applicant and if the
applicant is a private company, close corporation, partnership or trust, also if every shareholder,
member or partner thereof or beneficiary thereunder. (If the applicant or the said shareholder,
member partner thereof or beneficiary thereunder. (If the applicant or the said shareholder,
member, partner or beneficiary has no such interest, this fact shall be specifically mentioned.)

…………………………………………………………………………………………………………….

(Use an annexure if necessary)

(c) In the case of an application for a liquor store license, sorghum beer brewer’s license,
sorghum beer license for off consumption or a special license for off-consumption, is the
applicant-

(i) a producer or his agent? …………………………………………………. Yes No

(ii) a manufacturer of beer or his agent? …………………………………… Yes No

(iii) a person who has a financial interest in the business of a produce or a manufacturer
of beer, or the agent of such a person? ……………………………………. Yes No
 (iv) a company in which shareholders having a financial interest in the business of a
producer or a manufacturer or beer together hold a controlling interest, or the agent of
such a company? ……………………………………………………………. Yes No

(v) a company in which a company contemplated in subparagraph (c) (iv) holds a

controlling interest, or the agent of such a company? ……………………… Yes No

4. (a) State the kind of licence applied for ………………………………………………..

(b) State the kind of liquor applicant intends selling thereunder ……………............

…………………………………………………………………………………………….

5. If applicant is made for a wine farmer’s license-

(a) Is the applicant-
(i) a persona who engages in viticulture? …………………………………. Yes No
(ii) an association of persons the majority of the members of which engages in
viticulture? ………………………………………………………………. Yes No
(iii) a co-operative society [as defined in section 1 of the Wine and Spirit Control Act,
1970 (Act No. 47 of 1970).], which manufactures wine from grapes produced by
members of the co-operative society and of which no other such co-operation society
is a member? ……………………………………………………………. Yes No
(b) describe the situation of the premises where the liquor concerned is manufactured with
reference to the erf, street and farm number …………………………………………………......
………………………………………………………………………………………………………..
(Delete paragraph 5 if not applicable)
(Mark the applicable square)

6. If application is made for a producer’s license-

(a) is applicant a person who-
(i) engages in viticulture? ………………………………………. Yes No
(ii) manufactures any other fermented beverage? …………….. Yes No
(b) describe the situation of the premises where the liquor concerned is manufactured
with reference to the erf, street and farm number ……………………………………..
7. In the case of a special or sorghum beer license, state whether it is intended to sell liquor for
consumption on or off the licensed premises ………………………………………
8. Under what name is the business to be conducted? ……………………………….
9. (a) Describe the situation of the premises where the business is to be conducted by reference to
the erf, street or farm number ………………………………………………………

(b). In which district in the premises referred to in subparagraph (a); situated? ……………….

10. Will applicant have the right to occupy the premises referred to in paragraph 9, including such
place on other premises upon which any approval is to be exercised, for the purpose of the licence
applied for?
…………………………………………………………………………………………………………………

(Mark the applicable square)

11. In the case of an application for an on-consumption licence, state in which portion of the
premises the sale of liquor is to take place…………………………………………………………….
12. (a) Is application made in respect of premises which-
(i) have not yet been erected? ……………………………………………. Yes No
or
(ii) are already erected, but require additions or alterations to make them suitable for the
purposes of the proposed business? ………………………………….. Yes No
or
 (iii) are already erected and, in the applicant’s opinion, do not require additions or
alterations in order to make them suitable for such purpose? ………. Yes No

(b). If paragraph 12 (a) (i) or (ii) applies, state-

(i) the date on which such erections, additions or alterations will be commenced

with ……………………………………………………………; and

(ii) the period which will be required for the erection, additions or alterations ………..

13. (a) Is application made for any determination, consent, approval or authority which
may be granted by the competent authority? (e.g. other business or tasting facilities) …
(Mark the applicable square) Yes No

(b) If so, give full particulars with reference to the section in terms of which application
is made …………………………………………………………………….. Yes No

(Use an annexure if necessary)

14. In the case of a club liquor license, attach a copy of the rule of the club, certified by the
president, chairman or secretary thereof ………………………………………………….
Annexure …………………………………………………………………………………….

I declare / truly affirm that the information furnished in this application and in the documents
attached to it, is true.
Date ………………………………………………. ………………………………………………
Signature of applicant or person
authorized
to sign application
I certify that this declaration has been signed and sworn to/affirmed before me at ………………
this ………….day of………………………………..by the applicant/person authorized to sign
application who acknowledged that-
(i) he/she knows and understands the contents of this declaration;
(ii) he/she has no objection to taking the prescribed oath/affirmation; and
(iii) he/she considers the prescribed oath as binding on his/her conscience, and that
he/she uttered the following words:
“I swear that the contents of this declaration are true, so help me God.”
“I truly affirm that the contents of this declaration are true.”

…………………………………………………………….
Commissioner of Oaths
Full Name …………………………………………………………………………………………….
Business Address …………………………………………………………………………………….
Designation ………………………………………………………………………………………….
Area for which appointment is held ……………………………………………………………….
Office held if appointment is ex officio ……………………………………………………………