For the purpose of section 71(c) of the Act, the prescribed particulars for an application for the issue of a registration of premises to which this Division applies are—
(a) the date of the application; and
(b) the name and address of the proprietor; and
(c) the business name (if any) of the proprietor; and
(d) the class or classes of business to be conducted at the premises; and
(e) the address of the premises.