APPLICATION FOR ATTENDANT/TECHNICIAN CERTIFICATE

(Please tick appropriate box)

        INITIAL CERTIFICATE APPLICATION                     OR                RENEWAL OF EXISTING CERTIFICATE 

REQUIREMENTS BEFORE YOU LODGE THIS APPLICATION WITH THE COMMISSION
1.	Arrange to undergo fingerprinting with the Police - (contact the AFP on 6245 7351- 8am-4pm Monday to Friday).
2.	Complete this application form.
3.	Complete a Consent to Obtain Personal Information form - available from the AFP’s website at:
http://www.afp.gov.au/__data/assets/pdf_file/3683/crim01.pdf
4.	Take both completed forms with you when you attend the Police Station for fingerprinting.  After fingerprinting has been completed, you retain this form and the AFP will retain its form.
5.	Ensure that the Australian Federal Police endorse Page 2 (Section 6) of this application form.

Upon completion of the above requirements, you then lodge this application form with the Commission together with 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.

All applicants must complete Sections 1 to 6 and the Statutory Declaration at Page 3

SECTION 1 		(Please indicate which certificate applies by ticking appropriate box)
ATTENDANT 	TECHNICIAN 	
(A) INITIAL ISSUE REQUIREMENTS
Documentation/material required under sections 85 & 86 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.
•	4 recent passport-size photographs of the applicant.
•	Application Fee (see website).

	(B) INITIAL ISSUE REQUIREMENTS
Documentation/material required under sections
74 & 75 of the Gaming Machine Act 2004
•	A statement from each approved supplier that –
o	the supplier is satisfied that the applicant is competent to exercise the functions of an approved technician; and
o	the supplier employs or has offered to employ the applicant as a technician.
•	If the applicant is an approved supplier and is applying for approval to be a technician for their own business, then a statement to that effect is required.
•	4 recent passport-size photographs of the applicant.  
•	Application Fee (see website).	
RENEWAL REQUIREMENTS
•	Same documentation as at (A) above and 
•	Original Attendant Certificate OR a Statutory Declaration stating why the certificate cannot be produced.	RENEWAL REQUIREMENTS
•	Same documentation as at (B) above and
•	Original Technician Certificate and ID Card OR a Statutory Declaration stating why these documents cannot be produced.
	
Note:	A short-term approval for Attendants and Technicians may be issued under sections 87 and 76 of the Act subject to a satisfactory application.  A full-term approval may be issued under section 86 or section 75 of the Act pending the results of the police check.

SECTION 2
Applicant’s Surname                                                            Christian or Given Names

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

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

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

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

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

Have you previously been issued with a certificate of this nature in the ACT? (Initial Applicants Only) YES / NO

If yes, give details  …………………………………………………………………………………………………………

SECTION 4
RESIDENCES FOR THE LAST FIVE (5) YEARS
List all addresses at which you have resided during the last 
5 years.  (Account for all periods – dates MUST be continuous and  
include any period of no fixed-address and state a reason eg. travel)	Period you resided at Address

(Attach further information if insufficient space)	
Present Address:
	From           /       /              		

	From           /       /              	to         /      /	

	From           /       /              	to         /      /	

	From           /       /              	to         /      /	

	From           /       /              	to         /      /	

SECTION 5
Occupation FOR THE LAST FIVE (5) YEARS
List all work history, both full time and part time and if applicable all periods of unemployment during the last 5 years.  (Account for all periods – dates MUST be continuous).	Period of Occupation

(Attach further information if insufficient space)	
Present Occupation:
	From           /       /              		

	From           /       /              	to         /      /	

	From           /       /              	to         /      /	

	From           /       /              	to         /      /	

	From           /       /              	to         /      /	

SECTION 6

POLICE STAMP
Please stamp and date this area when fingerprints are taken.

 …….../……../…..…

I have requested the Australian Federal Police to check my criminal record using my 
fingerprints and have authorised them to report the results of the check to the 
ACT Gambling and Racing Commission.  I authorise the ACT Gambling and Racing 
Commission to use the results of the AFP check for the purposes of the 
Gaming Machine Act 2004.

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….…/……../………	

STATUTORY DECLARATION
in relation to an
Eligible Person under the Gaming Machine Act 2004

I, (Name)	_______________________________________________________________________________
(Address) of	_______________________________________________________________________________
		__________________________________________	Post Code____________________________
(Occupation) being a_________________________________________________________________________

Pursuant to the Gaming Machine Act 2004 of the Australian Capital Territory, solemnly and sincerely declare that the information provided in this declaration is true in every particular.

Date of Birth:		________________________________________________________________________
Place of Birth:		________________________________________________________________________
Citizenship Status:	_____________________________  If not born in Australia, proof of citizenship must be
                                                                      provided. (eg, naturalisation certificate, passport or certificate as evidence of residence)

Details of convictions or findings of guilt for any offences within the previous 5 years : (If none print NIL)________
____________________________________________________________________________________________________________________

Details of any bankruptcy or any payment arrangement with creditors at any time within the previous 5 years: (If none print NIL)_________________________________________________________________________________
____________________________________________________________________________________________________________________

Details of any corporation in which you were involved in the management of (at any time within the previous 5 years) where the corporation became the subject of a winding-up order or a controller or administrator was appointed (If none print NIL):_______________________________________________________________________

I, make this solemn declaration by virtue of the Statutory Declarations Act 1959 and subject to the penalties provided by that Act for the making of false statements in statutory declarations, conscientiously believe the statements contained in this declaration to be true in every particular.

____________________________________________________
Signature of Applicant

Declared at (place)_______________________________ on (date)_____________________________20_______

before me,

___________________________________________________      _________________________________________________
Signature of Witness				           Title of Witness 
						           (Witness must be an approved person under the
                                                                                                                        Statutory Declarations Act 1959)	
NOTE:   A person who intentionally makes a false statement in a statutory declaration under the Statutory Declarations Act 1959 is guilty of an offence under that Act, the maximum penalty for which is imprisonment for a term not exceeding four years.	

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)