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 in1￿matiOn
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
(DD1mP￿lYyY>
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 F￿sta7 address
of your community buildlng
Bullding Name
Emall andlor websi1• addross
Al1d￿sS
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)