SIAApplication 1-CB79P7 2632013115626-2

Licence AppIication Form
DO NOT HANDWRTE ANYTHNG ON THS PAGE AS T WLL NOT BE READ BY OUR COMPUTER SYSTEMS. F YOU NOTCE A MSTAKE
PLEASE LOG N TO OUR WEBSTE AND COPY THS APPLCATON TO A NEW APPLCATON, MAKE THE CHANGES AND PRNT YOUR FORM
AGAN.
0017444090512
AppIication ID
Please use this in correspondence or on the online tracker.
Your photograph should be standard passport size (44mm x 35mm).
Refer to the guidance notes** before enclosing your photograph. Please put your photograph loose in the envelope
and do not staple or stick it to this form.
** please see http://www.sia.homeoffice.gov.uk/licences or call 0844 892 1025 to request a copy.
AppIicant photograph
The applicant's photograph MUST be signed and dated in blue or black ink by their counter-signatory whose details are provided in section C of the
application form.
Section A - AppIicant detaiIs
A1.
A2.
A3.
A4.
A5.
A6.
A7.
A8.
TitIe
Surname/famiIy name
Forename
MiddIe name(s)
Gender
Date of birth
Country of birth
NationaIity
MR
ABOBAKER
MOHAMMED
Male
1/5/1961 (dd/mm/yyyy)
Sudan
DUTCH
A9. Any other country where you hoId citizenship
A10.
A11.
Do you have the right to work in the UK?
If yes provide a Home Office/Immigration reference number if known
Section B - Licence type
B1. What type of Iicence you are appIying for?
DS Sector code Front line RoIe
Section D - AppIicant verification and contact information
D1.
D3.
D5.
D9.
Do you have a UK NationaI
Insurance number?
Do you have a current vaIid
UK passport?
Do you have a UK driving
Iicence?
Are you now or have you ever been known by a different name?
Yes
No
Yes
D2. UK NationaI Insurance number SC555394C
UK passport number
UK driving Iicence number ABOBA605011M99DP
D4.
D6.
No
D7.
Do you have a current vaIid
overseas passport?
NNBC58503 Overseas passport number D8.
Yes
Application number: 0017444090512 Page 1
Printed for MOHAMMED ABOBAKER on 26/3/2013 11:56:17
AGAN.
D17.
D18.
D19.
D20.
EmaiI address (optionaI)
TeIephone number
Mother's maiden name
mhmdbb@yahoo.com
01162253586
ZANAB BRAHM
KHARTOUM BAHR Town of birth
Section E - Address history (for the Iast 5 years)
E1.
E2.
E3.
E4.
36 Upper Temple Walk Address
Leicester
LE4 0SB
E5.
England
Town/city
Postcode
Country
Resident from 4 - 2007 to -
Current Address :
Section F - MentaI heaIth
F1.
Have you been compuIsoriIy detained, or the subject of any other compuIsory measure under
mentaI heaIth IegisIation within the Iast 5 years?
No
Section G - CriminaI record information
G1.
Have you had a conviction, caution or written warning in the Iast 12 months? No
G2.
Have you been charged with an offence that is currentIy awaiting triaI? If "Yes" then pIease provide
detaiIs of the offence incIuding the LOCATION and DATE of when the charge was bought. No
H1.
Section H - Payment detaiIs
Licence appIication fee:
220.00
H2.
Is your empIoyer paying for your appIication (i.e. no payment is attached to this
appIication)? If so, this appIication must be submitted to your company and not
to the SIA.
No
AGAN.
H3.
H4.
H6.
H8.
H9.
H10.
H11.
H12.
Other payment methods
Card number
VaIid from date
Card hoIder's name
Card hoIder's biIIing
address
Town/city
Postcode
Country
Visa
xxxxxxxxxxxx2724
H5.
Issue number (if shown)
H7.
Expiry date 3 - 2013 2 - 2016
Mr Mohammed Abobaker
36 Upper Temple Walk
Leicester
LE4 0SB
England
D D M M Y Y Y Y
Signature date Signature of card hoIder
Data Protection Act and data sharing
understand that the SA will collect, store and use the information provided for SA licensing purposes. As a data controller under the Data
Protection Act 1998, the SA will process my information in accordance with the principles of that Act. understand that in order to consider my
application the SA, including its managed service provider, will process sensitive personal information about me. The SA will conduct a criminal
record check through the Disclosure and Barring Services (DBS), Disclosure Scotland or Access Northern reland (AccessN) about me. These
organisations or the SA may ask third parties for information about me or my application, including verification of my documents and identity.
understand that it is my responsibility to advise the SA of any changes to my personal details so my information can be kept accurate and up-to-date.
0017444090512
AppIication ID
Please use this in correspondence or on the online tracker.
You must complete every field and you and your counter-signatory must sign and date this form.
1. Applicant signature (We will not accept your application
unless you sign below in blue or black ink and your
signature is completely within the box.)
2. Signature date
C1. Counter-signatory surname/family name
C2. Counter-signatory forename
C3. Counter-signatory address
C4. Counter-signatory town/city
C5. Counter-signatory postcode
C6. Counter-signatory country
C7. Counter-signatory UK passport number
Counter-signatories should provide their current, valid UK passport
number (see guidance notes about counter-signatory identity)
C8. Counter-signatory telephone number
certify that the applicant (whose signature appears in Section ) is known to me and to the best of my knowledge and belief the details in
Section A are correct. understand that it is a criminal offence to knowingly make a false statement to the SA, and that the SA may use the
information provided by me in this section to confirm my details and identity and those of the applicant. By counter-signing and providing your
details, you are agreeing that the photograph is a true likeness of the applicant (whose signature appears in Section ).
C9. Counter-signatory signature (write within the box) C10. Counter-signatory date of signature
D D M M Y Y Y Y
confirm that have read and understand the SA licensing criteria (Get Licensed) and the guidance notes. agree to be bound by
the terms and conditions of holding an SA licence as outlined in the criteria. confirm that the information and documents have
provided in support of this application are, to the best of my knowledge, true and complete in every respect. understand that it is a
criminal offence under section 22 of the Private Security ndustry Act 2001 to knowingly or recklessly make a false statement to the
SA, and doing so may lead to my application being refused, my licence being revoked or suspended, and/or prosecution.
understand that information about my licence will be placed on a public register.
ABOBAKER
understand that the fees is for the application process and is non-refundable.
have read and understood the declaration on the Data Protection Act and data sharing on the previous page.
Applicant surname
|1
D D M M Y Y Y Y
1111111
0017444090512
What to do now
1. You must provide identification documents with your application. You must send either:
o Two identity documents from the group A Iist. At least one document must show your current address and at least one
document must show your date of birth.
Or
o One identity document from the group A Iist and two documents from the group B Iist. At least one document must show
your current address and at least one document must show your date of birth.
Group A documents
Signed valid passport of any nationality, or UK digital passport number entered on the application form (see our website
for information on digital passports).
Signed UK photo driving licence (both parts of the full or provisional licence are required).
UK original birth certificate issued within 12 months of birth.
Group B documents
Valid EU photo D card.
Valid UK firearms licence with photo.
Signed UK paper driving licence.
Marriage certificate or civil partnership certificate.
UK birth certificate issued more than 12 months after the date of birth.
Non-UK birth certificate.
P45 issued in the last 12 months.
P60 issued in the last 12 months.
Bank or building society statement issued in the last three months.
Mortgage statement issued in the last 12 months.
Utility bill issued within the last three months. You can onIy use a maximum of ONE utiIity biII.
Pension, endowment or SA statement issued in the last 12 months.
British work permit or visa issued in the last 12 months.
Letter from a Government department or a local authority issued within the last three months.
A credit card statement issued in the last three months.
Council Tax Statement issued in the last 12 months.
Child benefit book issued in the last 12 months.
UK adoption certificate.
AII address documents must show your current address and must be originaIs. We cannot accept two documents from the same
issuer or body. There are exemptions to the document ruIes. PIease read the Specific Guidance Notes you were given after fiIIing in
your detaiIs or see our website.
f you send your application by recorded or special delivery, please retain your receipt and counterfoil.
2. f you have not previously held a SA licence you must provide a passport sized photograph (signed and dated on the back by your
counter-signatory in black or blue ink, with your name and date of birth).
3. You must provide a payment either a cheque or with card details on the application form (unless your application is being submitted
and paid for through the bulk application process).
4. You must make sure your counter-signatory signs and dates Section C in black or blue ink (f the counter-signatory details were not
filled in online, you must complete them by hand before you send in your application form).
5. You must sign and date the declaration at the end of the form in black or blue ink.
Send your application form, photograph, payment and documents to: SIA Document HandIing Centre, PO Box 1290, LiverpooI, L69 1AS

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Licence AppIication Form

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