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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 			MACHINE DETAILS AND FEES	

PLEASE PROVIDE ALL MACHINE DETAILS ON PAGE 2 OF THIS APPLICATION FORM

FEES for Machine Conversions	See payment options on last page	  No. of 
  Machines	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:......../......../........		

 	 MACHINE SELECTION - Conversion		
Licensee:	 		 	 	 	 	 	 	 	
 	 	 	 	 	 	 	 	 	 	
 	Serial	Machine	Max.	Coin	%	Var.	TICKET	LINK (Yes/No)	LINK %	
 	No.	Name	Coins	Value	Return	No.	YES/NO	APPROVAL No	CONTRIBUTION	
1)  From	 
 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
2)  From	 
 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
3)  From	 
 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
4)  From	 
 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
5)  From	 
 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
6)  From	 
 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
7)  From	 
 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
8)  From	 
 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
9)  From	 
 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	

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)