APPLICATION TO TRANSFER/AMEND 
APPROVED ATTENDANT/TECHNICIAN CERTIFICATE

When lodging this application form with the Commission please ensure that you attach all other documentation/material detailed in Section 1 below.   Please note that applications completed incorrectly or submitted without all the required documentation/material will not be processed.

SECTION 1           (Please indicate which amendment to your certificate you are seeking)
•	Transfer Certificate to new licensee/supplier 
•	Add additional licensee/supplier to existing Certificate
•	Remove a licensee/supplier from existing Certificate 
In relation to:	
	An Attendant Certificate		A Technician Certificate	
Documentation/material required under sections 89 of the Gaming Machine Act 2004
•	A statement from each licensee that the licensee employs, or has offered to employ, the applicant as an attendant.
•	Application Fee.
•	Original Attendant Certificate OR a Statutory Declaration stating why the certificate cannot be produced.
	Documentation/material required under sections 78 of the Gaming Machine Act 2004
•	A statement from each approved supplier that –
a)	the supplier is satisfied that the applicant is competent to exercise the functions of an approved technician; and
b)	the supplier employs or has offered to employ the applicant as a technician.
•	Application Fee.
•	Original Technician Certificate and ID Card OR a Statutory Declaration stating why these documents cannot be produced.	

SECTION 2
Applicant’s Surname                                                                     Christian or Given Names

……………………..……………………………………….…………………….………………………………

Phone  (Home)  …………………………………………...……..  (Mobile)  ………………………………….

SECTION 3
Name of the new Licensee or Approved Supplier with whom you are or will be employed:

…………………………………………………………………………………………………………………….

Phone  …………………………………………  Facsimile  ……………………..………………………………	

SECTION 4
I request the ACT Gambling & Racing Commission amend my certificate according to the information provided above.

Signature of Applicant  ……………………………………………………………Date……../………./………
This section for office use only – gaming section

Certificate Number                                                    Short Term Approval Issued ____/____/____ Expiry ____/____/____

                                                                                   Full Term Approval Issued   ____/____/____ Expiry ____/____/____
	
APPLICATION FEE PAID	YES	NO	

Delegate of the Commission  ……………………………………………  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)