MANUFACTURER		
ADDRESS		
CONTACT NAME		PHONE		
		FAX		

EQUIPMENT DETAILS

SYSTEM/DEVICE NAME		
DESCRIPTION		
CATEGORY		
SPECIFICATION OR SERIAL NUMBER		
TECHNICAL STANDARDS		
SUBMISSION STANDARDS		

I, ……………………………………………………………………………………………………………………………………
	                                                         (print full name)		
 
do hereby declare that the information on this application form is true and correct.

Signature…………………………………….….  Position with Company………………………………….Date        /         /       

OFFICE USE ONLY – GAMING SECTION	
APPLICATION FEE PAID	YES		RECEIPT NUMBER:		
TECHNICAL APPROVAL 	YES		APPLICATION APPROVED	YES	NO	
NOTIFIED IN LEGISLATION REGISTER	YES				
(Date of Notification)

……../………./……...				APPROVAL NO. …………………………………

…………………………………………
Signature of Delegated Officer   Date……./……../…….	

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)