Lisburn Online Forms -

Application for Sports Ground Safety Certificate for a Designated Venue

Venue Details
Name of Venue:
Name of Club or Organisation that operate venue:
Address of Venue (inc postcode):
Principle contact at venue and Address for correspondence (if different from above)
Name:
Address (inc postcode):
Phone Number:	+
Mobile Number:
Email:
Fax Number:
Name of Applicant (also known as the qualified person):
Address (inc postcode):
Phone Number:	+
Mobile Number:
Email:
Status/Role of proposed qualified person within the management of the venue:
Please attach a photocopy of the minute relating to the nomination of the Applicant/Qualified Person
How was the decision made regarding the appointment of this person?:
Has the decision been included in minutes of a Committee Meeting, Board Meeting?:
How was this decision conveyed to the individual?:
Have they accepted this role?:
List of Sports to be played at the venue to be included in a General Safety Certificate:
Cost
Fees:

For further information please contact ehealth@lisburn.gov.uk +44 (0)28 9250 9394

Data Protection Act 1998

Lisburn City Council collects the data on this form for the purposes of the management and application of the LG (MP) (NI) Order 1985. This data may be passed to other relevant Government agencies.