APPLICATION TO CHANGE LICENSED PREMISES

If insufficient space is available for responses please attach additional information.

SECTION 1
Name of applicant		
Address of applicant		
Contact Name		Contact Phone No.		
Trading name of premises		Licence No.		
Address of premises		
Block		Section		Suburb		

SECTION 2:  I wish to apply to amend the licence BY (tick to select):
	Moving the gaming machines to different premises. 			Structurally changing a part of the premises where the licensee is allowed to operate gaming machines.	
					
Documents Required

•	Social Impact Assessment
•	Statement setting out the reasons for the amendment (such as lease expired).
•	Evidence that the majority of voting members voted for the amendment.
•	Scale drawings of the premises showing the proposed layout of machines.
•	Audited financial statements for the three previous financial years.
•	Copies of all contracts or proposed contracts relating to the use of the premises proposed to be licensed.
•	Licensee’s expected revenue and expenditure for the next three years.	Relevant Section of Act

22(2)(b)

23(1)(c)

24(3)(a)
Regulations, Part 4

24(3)(c)

Regulations, section 6(2)

Regulations, section 6(2)

Regulations, section 6(3)
		Documents Required

•	Statement setting out the reasons for the amendment.
•	Scale drawings of the premises showing the proposed layout of machines.	Relevant Section of Act

23(1)(c)

39A, 13(1)(b)

SECTION 3
TO BE COMPLETED BY THE APPLICANT (OR SECRETARY IF A CLUB)

I,....................……..…………….….. on behalf of ...........………………………………………………………………
	(Print full name)					(Name of Applicant Organisation)

do hereby declare that the information on this application form and the accompanying documentation is true and correct.

Signed...............................................…………………............................................Date......................………..

THIS SECTION FOR OFFICE USE ONLY – GAMING SECTION	
APPLICATION FEE PAID	YES	NO	

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: 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)