Gaming Machine Act 2004
Sections 74 and 75

APPLICATION FOR AN 
APPROVED TECHNICIAN CERTIFICATE
****Important Information for Applicants****

1.	This application must be completed in full in black or blue print.  Any question or section left unanswered or blank may result in the application form being returned to the applicant OR may result in the application not being considered. If a question does not apply or there is nothing to disclose insert “N/A”.

2.	As part of the application process an applicant is required to undergo fingerprinting through the Australian Federal Police (AFP).  Appointments can be made by telephoning the AFP on 6245 7351.

3.	Applicants must also complete and submit to the AFP a “Consent to Obtain Personal Information” form available from the AFP website: http://www.afp.gov.au/business/national_police_checks.html.  The return address should be recorded as: 	ACT Gambling & Racing Commission
PO Box 214
CIVIC SQUARE  ACT  2608

4.	Applicants are required to attach the following documentation to their application:
•	a fully completed Statutory Declaration in relation to an Eligible Person (see Attachment to application); 
•	a written statement from each approved supplier/employer stating that the applicant is competent to perform the functions of a technician and is employed or has offered to employ the applicant as an Approved Technician;
•	if applicant is applying for a certificate in respect of their own business a written statement is to be submitted to this effect;
•	a record of appointment for fingerprinting with the AFP;
•	a certified copy of the applicant’s full birth certificate (not an extract) or current passport;
•	a certified copy of another form of identification eg. driver’s licence, Medicare/credit/bank a/c card (cards should be photocopied on both sides);
•	an original or  certified copy of the applicant’s consumer credit report (not an extract) dated within 1 month of lodging an application.  Reports may take a minimum of 10 working days to process and can be obtained from VEDA ADVANTAGE http://www.mycreditfile.com.au/home/home_default.aspx or DUN & BRADSTREET http://www.dnb.com.au/general/check_your_profile.asp).
•	if applicant’s name has changed, certified copies of supporting documentation such as a deed poll or marriage certificate;
•	four (4) recent passport photographs with applicant’s name clearly printed on the back;
•	if born overseas, certified proof of Australian Citizenship, permanent residency or visa documentation permitting applicant to live/work in Australia; and
•	if not an Australian Citizen, an applicant must provide a certified copy of a current police criminal check from their country of origin if they have resided in Australia for less than 5 years.

5.	Applicants should ensure that they sign and date each page where required and note that failure to provide true, correct and full disclosure to any question on this form may result in the application being rejected.

6.	If the space provided is insufficient to answer a question, please present relevant information on a separate attachment page. 

7.	When completed, this application form, the required documentation, Statutory Declaration and determined fee should be forwarded to: 	ACT Gambling & Racing Commission
PO Box 214
CIVIC SQUARE  ACT  2608

PERSONAL INFORMATION	

		Mr/Mrs/Miss/Ms (Circle) 			Male            Female  

   …………………………….…………… 	…………………………………		……….………………………
			  Surname 					    Given Name 				Middle Name/s

Other Names (aliases, nicknames, former names, maiden names) ……………………………………………………………….

Date of Birth: ......../……./…….. 		Country of Birth: ……………………..………………………………………….

Residential address and contact details:

………………………………………………………………………………   ……………………………………………..
				Street 								Suburb
………………………………………….   ……………………
		State 				Postcode

Telephone: (………) ………………………….………….………..   Mobile Number: …………………………………....

Email address: ……………………………………………………………………………………………………………….	

Postal address: (if the same as the address provided above write “as above”)

………………………………………………………………………………   ……………………………………………..
				Street 								Suburb
………………………………………….   ……………………
		State 				Postcode

Are you an Australian Citizen?   YES            NO
If you are a naturalised citizen of Australia state: (i)  date and place of naturalisation …….……………………………….
						(ii) certificate number. …………………………………………………..

If you are a citizen of another country, state the country: …………………………………………………………………..

VISA category and number: …………………………………………………………………………………………..…….	

Photographs:

Securely attach four (4) colour passport photographs to your application.  Ensure your name is clearly printed on the back of each photograph.
	
Certificate information	

Name of the Supplier(s) with whom you are or will be employed:

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

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

Have you previously been issued with an Approved Technician Certificate in the ACT? :       YES            NO

If yes, please provide:	
Certificate number	Supplier/Employer	

RESIDENCES	
List all addresses at which you have lived during the past 5 years.
ACCOUNT FOR ALL PERIODS – dates must be continuous, with no gaps.  
Include any period of no fixed address and state reason eg. travel.	
From	To	Address	City/State/Country	Post Code	
Example
10/10/2005	10/1/2006	ANU – Bruce Hall	Canberra, ACT	0221	
    /    /	Present				
    /    /	    /    /				
    /    /	    /    /				
    /    /	    /    /				
    /    /	    /    /				
    /    /	    /    /				
    /    /	    /    /				
    /    /	    /    /				
    /    /	    /    /				
EMPLOYMENT	
List all of your work history, both full and part time, and if applicable all periods of unemployment, schooling and all businesses with which you have been involved during the past 5 years.
ACCOUNT FOR ALL PERIODS – dates must be continuous, no gaps.	
From	To	Occupation	Employer Name	
Example
10/10/2005	10/1/2006	Student 	ANU	
    /    /	Present			
    /    /	    /    /			
    /    /	    /    /			
    /    /	    /    /			
    /    /	    /    /			
    /    /	    /    /			
    /    /	    /    /			
    /    /	    /    /			
Have you ever been dismissed, retrenched or suspended by an employer? 
					 YES     NO   (if yes provide details below).

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

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

BUSINESS AFFILIATIONS	

List all business, partnerships, joint ventures, etc. with which you are currently associated and in which you actively participate in the management or operation thereof.  Indicate any direct or indirect financial interest in any business.

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

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

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

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

AUTHORISATION 

ACT GAMBLING AND RACING COMMISSION
To:	All courts, probation departments, employers - current and previous, educational institutions, legal practitioners, banks, financial and other institutions, all agencies - Federal, State and Local, both foreign and domestic and to whomsoever else this authorisation may be duly presented. 
From:	…………………………………………………………………………………………………
 		Surname			 Other Names	
 of:  ……………………………………………………………………………………………………
 	Street				Suburb			State		Postcode
Date of Birth:	…… /……/…..
I hereby authorise the ACT Gambling and Racing Commission ("the Commission") and the Australian Federal Police ("the Police") to conduct investigations into my background for the purpose of assessing my suitability to obtain or maintain an Approved Technician Certificate under the provisions of the Gaming Machine Act 2004. 
I HEREBY AUTHORISE the Commission and the Police to access, inspect and obtain copies of: 
(a) 	any credit report, other report, legal or personal information derived from those reports that has any bearing on my credit worthiness, credit history, credit standing or credit capacity; 
(b) 	any loan information, cheque account records, savings deposit records, safe deposit box records, passbook records and bank statement sheets pertaining to me. 
(c) 	any records relating to investigations of my activities conducted by any State, Territory, Federal or overseas police force, crime investigation agencies, corporate regulatory agencies or any gaming or casino regulatory authorities; 
(d) 	any court records relating to any present or past civil or criminal court proceedings to which I am or was a party; and 
(e) 	any other document, record or correspondence pertaining to me. 
You are HEREBY AUTHORISED to release to the Commission or the Police all the documents, reports, records and information requested by them. 

One of the purposes for which this Authorisation has been given is to satisfy Section 18N(1) (ga(ii)) of the Commonwealth Privacy Act 1988 which provides that a credit provider may only disclose information when the individual concerned has provided written permission. 

Signed: ………..…………………………………..… Date:    /     /
			Applicant’s signature

CHECKLIST FOR APPLICANTS PRIOR TO APPLICATION LODGEMENT
1.	All dates completed in the form Day/Month/Year.
2.	Signatures and dates are inserted where indicated. 
3.	ALL required attachments (refer to table below) are attached.  
An application NOT accompanied by ALL of the required attachments and the correct application fee is considered incomplete and may be returned to the applicant or may not be considered further by the Commission

Provided	The following must be submitted WITH the application	
Yes/No	The determined fee.     NOTE: This fee is not refundable.	
Yes/No	A written statement from each supplier/employer stating that the applicant is competent to perform the functions of a technician and is employed, or has offered to employ the applicant as a Technician.	
Yes/No	If applicant is applying for a certificate in respect of their own business a written statement to this effect.	
Yes/No	A record of appointment for fingerprinting with the Australian Federal Police.	
Yes/No	Four (4) recent passport photographs of the applicant (name printed clearly on the back of each photo).	
Yes/No	Certified copy of applicant’s full BIRTH CERTIFICATE (not an extract) or applicant’s current PASSPORT.	
Yes/No	Certified copy of another substantial form of identification (eg. driver’s licence, credit card, bank account).	
Yes/No	If born overseas, a certified copy of your Australian Citizenship, Permanent Residency Certificate or Visa permitting you to live or work in Australia.	
Yes/No	If NOT an Australian Citizen a certified copy of a current police criminal check from the applicant’s country of citizenship is required for applicants who have resided in Australia for less than 5 years.	
Yes/No	If the applicant’s name has changed, a certified copy of all the supporting documentation, eg. Marriage Certificate, Deed Poll.	
Yes/No	The original or a certified copy of the applicant’s CONSUMER CREDIT REPORT (not an extract) dated within 1 month of lodging this application.  Credit checks  may be obtained from:
VEDA ADVANTAGE  http://www.mycreditfile.com.au/home/home_default.aspx  or 
DUN & BRADSTREET  http://www.dnb.com.au/general/check_your_profile.asp 
It is important to allow a minimum of 10 working days for processing.	
Yes/No	A fully completed Statutory Declaration in relation to an Eligible person under the Gaming Machine Act 2004.	
*Additional Notes:
1.	During the period in which this application is being processed and after any Certificate may have been issued, the applicant must notify the ACT Gambling and Racing Commission of any change in the applicant’s address or any other matter set out in this application.
2.	Failure to provide a true, correct and complete answer to any question on this form may result in a refusal to grant a licence or the suspension or cancellation of any licence issued.  A person who makes a declaration that is to his or her knowledge false in a material particular may be liable to prosecution for an offence under the Statutory Declarations Act 1959 (Commonwealth).
OFFICE USE ONLY
Certificate Number:	Short Term approval issued with expiry date of:            /              /          	
	Full approval issued with expiry date of:              /              /          	
Signature of approving
Delegate of the Commission  ……………………………………………  Date…...…/….…../………	

PRIVACY POLICY

Personal information supplied by an applicant is collected, used and stored in accordance with the Privacy Act 1988 and the ACT Gambling and Racing Commission’s privacy policy.  A full copy of the Commission’s privacy policy may be obtained either from its website at http://www.gamblingandracing.act.gov.au or by contacting the Commission’s Privacy Contact Officer on telephone 6207 0359.  

In accordance with the Information Privacy Principles you are able to gain access to any personal information held about you by the Commission.

Payment details

Important Information
The prescribed fee must accompany an application for an Approved Technician Certificate.  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 website: http://www.gamblingandracing.act.gov.au/TheCommission/Fees.htm  Otherwise, contact the Commission on 6207 0359.	

Please indicate the method of payment:
•	money order or cheque made payable to the ACT Gambling and Racing Commission;
•	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)
Card Number: _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _  Expiry Date: __/__
Name on Card: ……………………………………….….   Signature: ………………………………………..

This section for office use only

Processed by: …………………………….…………………. Date: ……./……./……. Reference Number: ……………….
 			(Authorised Officer)	

Applicant’s signature: ………………..………………………   Date: ……/……/…...

Commonwealth of Australia
STATUTORY DECLARATION
In relation to an Eligible person under the Gaming Machine Act 2004
Gambling and Racing Control Act 1999 (section 53D)
	
Pursuant to the Gaming Machine Act 2004 (the Act) of the Australian Capital Territory,
I,    _____________________________________________________________________________________
                                                                                         (FULL NAME)

of   _____________________________________________________________________________________
                                                    (STREET)                                              (SUBURB)                            (STATE)                  (POSTCODE)

being a  _________________________________________________________________________________
                                                                              (OCCUPATION)
do solemnly and sincerely declare that the information provided in this declaration is true and correct in every particular.	
	Date of Birth:_____________ Place of Birth:___________________________ Australian Citizen?  YES   NO	
	If you answer YES to any of the following questions please provide details in the space provided below.	
	Within the last five (5) years have you been convicted or found guilty of any criminal or civil offence anywhere?	 YES   NO	
	Within the last five (5) years have you been an undischarged bankrupt, applied to take the benefit of a law for the relief of bankrupt or insolvent debtors or compounded with creditors or made an assignment of remuneration for their benefit?	
 YES   NO	
	Within the last 12 months have you had an application for approval as an Attendant or Technician refused?	 YES   NO	
	Within the last 12 months have you had an approved Certificate as an Attendant or Technician cancelled or suspended?	 YES   NO	
	Within the last 12 months have you had an application for approval as a Gaming Machine Licensee or Supplier refused?	 YES   NO	
	Within the last 12 months have you had a Gaming Machine or Supplier licence cancelled or suspended?	 YES   NO	
	Within the last five (5) years have you been involved in the management of a corporation when it became the subject of a winding up order or it had a controller or administrator appointed?	 YES   NO	

		

		

		

		

		

	I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true and correct in every particular.

Signature of Applicant  ___________________________________________  Date:  _______/______/______	
	Declared at  __________________________________ on ______ of ________________________________
                                                           (Place)                                                     (Day)                                   (Month and Year)
Before me, ___________________________________ Name of Witness ______________________________
                                     (Signature of Witness)                                                                                    (FULL NAME IN BLOCK)	
	of   _____________________________________________________________________________________
                                                   (STREET)                                               (SUBURB)                            (STATE)                        (POSTCODE)
QUALIFICATION:__________________________________________________________________________
(see below)	
Note 1   A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is 
	      imprisonment for a term of 4 years — see section 11 of the Statutory Declarations Act 1959.
Note 2   Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 - see section 5A of the 
	Statutory  Declarations Act 1959.
*********************************************
A statutory declaration under the Statutory Declarations Act 1959 may be made before–
(1) a person who is currently licensed or registered under a law to practise in one of the following occupations:
Chiropractor			Dentist			Legal practitioner		Patent attorney	
Medical practitioner		Nurse			Optometrist		Pharmacist	
Physiotherapist		Psychologist		Trade marks attorney		Veterinary surgeon
(2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described); or
(3) a person who is in the following list:

Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public
Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)
Bailiff
Bank officer with 5 or more continuous years of service
Building society officer with 5 or more years of continuous service
Chief executive officer of a Commonwealth court
Clerk of a court
Commissioner for Affidavits
Commissioner for Declarations
Credit union officer with 5 or more years of continuous service
Employee of the Australian Trade Commission who is:
(a) in a country or place outside Australia; and
(b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and
(c) exercising his or her function in that place
Employee of the Commonwealth who is:
(a) in a country or place outside Australia; and
(b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and
(c) exercising his or her function in that place
Fellow of the National Tax Accountants’ Association
Finance company officer with 5 or more years of continuous service
Holder of a statutory office not specified in another item in this list
Judge of a court
Justice of the Peace
Magistrate
Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961
Master of a court
Member of Chartered Secretaries Australia
Member of Engineers Australia, other than at the grade of student
Member of the Association of Taxation and Management Accountants
Member of the Australian Defence Force who is:
(a) an officer; or
(b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or
(c) a warrant officer within the meaning of that Act
Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants
Member of:
(a) the Parliament of the Commonwealth; or
(b) the Parliament of a State; or
(c) a Territory legislature; or
(d) a local government authority of a State or Territory
Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961
Notary public
Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postal services to the public
Permanent employee of:
(a) the Commonwealth or a Commonwealth authority; or
(b) a State or Territory or a State or Territory authority; or
(c) a local government authority;
with 5 or more years of continuous service who is not specified in another item in this list
Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made
Police officer
Registrar, or Deputy Registrar, of a court
Senior Executive Service employee of:
(a) the Commonwealth or a Commonwealth authority; or
(b) a State or Territory or a State or Territory authority
Sheriff
Sheriff’s officer
Teacher employed on a full-time basis at a school or tertiary education institution