Title: This application must be accompanied by the determined fee
Author: tamara grocott
Last saved by: Anna Anderberg!
Company: ACT Government

Gambling and Racing Control Act 1999, s 53D
GAMING MACHINE ACT 2004

Gaming Machine Act 2004					
Application for Technical Licence Amendment 
Single-User Linked Jackpot Arrangement

APPLICATION FOR TECHNICAL LICENCE AMENDMENT
 SINGLE-USER LINKED JACKPOT ARRANGEMENT

If insufficient space is available for responses please attach additional information

SECTION 1				DETAILS OF APPLICANT
Name of Licensee
Name of Premises
Licence No.
Address
Contact Name
Phone | Fax | Email

SECTION 2				DETAILS OF SUPPLIER
Name of Supplier
Contact Name
Phone | Fax | Email

SECTION 3		LINK DETAILS/FINANCIAL INFORMATION AND FEES
PLEASE PROVIDE LINK DETAILS ON PAGE 2 OF THIS APPLICATION FORM AND
ENSURE THAT YOU COMPLETE THE FINANCIAL ARRANGEMENTS ON PAGE 3.

See payment options on last page | Total Remittance Due | $

SECTION 4

I, _______________________________(print full name) of ______________________________(name of licensee) 

do hereby declare that the information on this application form and the accompanying documentation is true and correct and that all financial arrangements have been declared.

______________________(Signature)___________________________(Position) _____/____/_____ (Date)

THIS SECTION FOR OFFICE USE ONLY – GAMING SECTION

APPLICATION
FEE PAID

YES

NO

APPROVAL NUMBER

| | | | | | | _____________________

APPLICATION
APPROVED

YES

NO

FINANCIAL
ARRANGEMENT

YES

NO

| | | APPROVED | | | |
SIGNATURE: | DATE:......../......../........ |

PARTICULARS OF SINGLE-USER LINKED JACKPOT ARRANGEMENT

L Licensee:                                           Premises:
Details of start up/re-set amounts and contribution rates

LINK DETAILS | | | |
Manufacturer Name | | | |
Address | | | |
Name of System | | | |
Specification No | | | |

Identify Type of Link
(please tick one only)

CCCE

Hyperlink

Normal

PRIZE SCHEDULE

MAXIMUM
JACKPOT

Reset Amount
$/Coins             %

CONTRIBUTION
PERCENTAGE

TOTAL%

TOP JACKPOT | | | | |
SECOND JACKPOT | | | | |
THIRD JACKPOT | | | | |
FOURTH JACKPOT | | | | |
HIDDEN/BACKUP | | | | |
TOTAL CONTRIBUTION PERCENTAGE | | | | |

FINANCIAL PARTICULARS FOR SINGLE-USER LINKED JACKPOT ARRANGEMENT

This form must be completed when Linked Arrangements are to be purchased.
A copy of the proposed contract between the Licensee and Supplier for the purchase of any link must accompany this form.

Licensee:
Premises Name:
Contact Name:

Supplier’s Name:

Details of the proposed contract for acquisition
(including any proposed order) must be attached.

$

TOTAL PURCHASE PRICE (inc GST)             

SOURCE OF FINANCE
1. Cash from licensee’s funds: | $

Name of institution
    where funds are held:

Address: |

2. Other source: (Provide details of all relevant financial arrangements, including
    loans, guarantees, delayed payment plans)

Type of financial agreement: |
Provider of finance: |
Address of provider: |
Duration of Agreement: | Years: | Months:

Other Details: ______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________

Important Information

The prescribed fee must accompany this application.  Please note that once an application is submitted to the ACT Gambling and Racing Commission the application fee is non-refundable.

The prescribed fee is available on the Commission’s web site at:

www.gamblingandracing.act.gov.au

Alternatively, you can contact the Commission on 6207 0359 for more information.

Post application to:
               ACT Gambling and Racing Commission PO Box 214   CIVIC SQUARE ACT 2608

Please indicate by ticking the appropriate box which of the following will be the method of payment:

•	money order or cheque made payable to the ACT Gambling and Racing Commission; or

•	credit card (Visa or Master Card).  Please complete the required details in the area provided below.

Payment by credit card

Card type	  Master Card	  Visa	    Amount $ ....……..(maximum of $3,000.00)

Card Number     Expiry Date: .…./….

Name on Card: ………….…………………..…….. Signature: ………………….………………..

This section for office use only – finance section

Payment
Processed by: ……………………………………..…. Date: …..../……../.…….    Receipt Number: …………….
		      (Authorised Officer)

AF2007-2                    2^nd floor, Canberra Nara Centre, 1 Constitution Avenue, Canberra City 2601
PO Box 214 CIVIC SQUARE ACT 2608
Homepage:  http://www.gamblingandracing.act.gov.au
Unauthorised version prepared by ACT Parliamentary Counsel’s Office

Unauthorised version prepared by ACT Parliamentary Counsel’s Office