Billing Detslls: Address If the details of the pfrrson you want us to deal with have changed, please provide the new contact detsils uslng th¢ box below. In compliance wlth the Data Prolecb'on Act the folluwirvj information 11 be Stored on txjr database arNJ will only be useij by us vthen contactin9 y(KJ for in1matiOn the at4)ve community building. Title Postcode Forename Email Surnamé Telephone no. Positlon e.g. Treasurer. ChairrNqn. other Please speclfy when It Is convenlent for us to call Conta Email referenc Post rfi I0-3Y- Additional Information The PRS for Music and PPL tariffs 1h provide the basis for yourjoint licence fee calculation. To ensure your retums are as simple as possible with minimum administration on your part, both tariffs define 'income' in the same way, as detailed on the front of this forrn. However, there are a few differences in the charges and exdusions frorn the tsriffs, which are summarised below. Full versions of the tariffs are available by post on request, or online al PPLPRS.co.uk. You can also call us for more infomiation on 0800 0720 808. Community 8uildlng8 covered ty l)oth tarlffs Community buildings run by voluntary organisations such as Community c£nlres, villagelrnemoriallparochial halls. separate church halls serving Ihe communily at large women's institutes. welfar8 inslitules and Mmpaiabl8 premises that feature music at a variety of entertainment funclions. Community Buildings not covered by either tariff
Income Declaration (DD1mPlYyY> Defined Income From last available annual accounts for year endèd: (31 J Ipl £611? We run events that a ticketed aly)ve £20.. Yes (If yes. please prowde details) We use recorded music in evenlslacuvitieslareas ourselves". Yes No Ilf yes. please provide details) Declaration Full name of signatory (Print name and posltion) and offKe held, (vthore appropriate) I confirm that the above details are correct at the time of writing and that l am authorised by my organisation to request that PPL PRS Ltd follow the insiructions above in dealing with our account. ¥Q(J¥•f Authorlsed signatory ft)rlon behall of organisallon (signature Telephon• no. Cuslomer Details leg chaTIty, 11m1t company, commlttee): Please confirm below the full nam8 arKI Fsta7 address of your community buildlng Bullding Name Emall andlor websi1• addross Al1dsS What Is the full name of th• body responslble for runnlng the venue? e.g. committee's name. asscoation name. parwhlal church ossocialion et¢. Postcode -d &woAhr4 ..[ Please Ilck Voluntary organisalion Registered charity please prowde L*arity registration no.) Other (please specify)