GAMING MACHINE ACT 2004	
Form made pursuant to Gambling and Racing Control Act 1999, s 53D	

APPLICATION FOR TECHNICAL LICENCE AMENDMENT	
MACHINE CONVERSION	
	
SECTION 1	DETAILS OF APPLICANT	
Name of Licensee	 	
Trading Name	 	Licence No.	 	
Venue Address	 	
Postal Address	 	
Contact Name	 	
Contact Details	Phone 		Fax		 Email		
		
SECTION 2	DETAILS OF SUPPLIER	
Name of Supplier	 	
Postal Address	 	
Contact Name	 	
Contact Details	Phone 		Fax		 Email		
		
SECTION 3	FEES PAYABLE	
No. of Machines	 	Total Remittance Due 	 $	For payment options see last page	
		
SECTION 4	DECLARATION	
I,  _________________________________________________ of  _________________________________________________	
(print full name)                                                                                                                	(name of licensee)	
do hereby declare that the information on this application form and 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	
 		Yes	No					
APPROVAL NUMBER

___________________	
Application Fee Paid	¨	¨			
Application Approved	¨	¨	SIGNATURE: _______________________________		
Financial Arrangement
Approved	¨	¨	DATE: _____________________________________		

										
AF2009-185	2nd Floor Canberra Nara Centre, 1 Constitution Avenue, Canberra City 2601
PO Box 214 CIVIC SQUARE  ACT  2608
Homepage: http://www.gamblingandracing.act.gov.au

Gaming Machine Act 2004									
Application for Technical Licence Amendment - Machine Conversion								
		
SECTION 5	MACHINE SELECTION	
Trading Name:	Licence No:	
 	Serial No		Machine Name	Base Credit Value	% Return to player	Variation No.	 Ticket Out 
Yes / No	* Link 
Approval No.	Link %
Contribution	
1		To:	 	 	 	 	 	 	 	
		From:	 	 	 	 	 	 	 	
2		To:	 	 	 	 	 	 	 	
		From:	 	 	 	 	 	 	 	
3		To:	 	 	 	 	 	 	 	
		From:	 	 	 	 	 	 	 	
4		To:	 	 	 	 	 	 	 	
		From:	 	 	 	 	 	 	 	
5		To:	 	 	 	 	 	 	 	
		From:	 	 	 	 	 	 	 	
6		To:	 	 	 	 	 	 	 	
		From:	 	 	 	 	 	 	 	
7		To:	 	 	 	 	 	 	 	
		From:	 	 	 	 	 	 	 	
8		To:	 	 	 	 	 	 	 	
		From:	 	 	 	 	 	 	 	
9		To:	 	 	 	 	 	 	 	
		From:	 	 	 	 	 	 	 	
10		To:	 	 	 	 	 	 	 	
		From:	 	 	 	 	 	 	 	
*If an amount available as a prize in a linked-jackpot arrangement has not been won, and cannot be won because authorisation for the arrangement has been cancelled or surrendered, then the licensee must write to the Commission seeking approval to redistribute the amount as a prize, or an addition to another jackpot.  If the Commission approval is not given within 4 weeks after the linked-jackpot authorisation is cancelled or surrendered then the amount is forfeited to the Territory.

Gaming Machine Act 2004	
Application for Technical Licence Amendment -  Machine Conversion	
		
SECTION 6	FINANCIAL ARRANGEMENTS	

Copies of documents related to proposed financial arrangements to finance or encumber a gaming machine being converted need to be attached.  An encumbrance includes any Intellectual Property (IP) licence fee applying in respect of the converted gaming machine. 	
	Y	N	
Does an Intellectual Property licence fee apply to any of the gaming machines being converted? 			
				
Total Purchase Price of Conversion/s (inc GST)		$	 	
							
Source of Finance							
1. Cash from licensee's funds:	$			 	
    Name of institution where funds are held:			 	 	
    Address:							 	 	
										
2. Other source:	$				
					
Type of financial agreement:*			 	 	 	 	 	
Provider of finance:				 	 	 	 	 	
Address of provider:				 	 	 	 	 	
Duration of Agreement:				Years:	 	Months:	 	
*A copy of the financial contract must accompany this application.	
										
Other Details:										

										

										

 	 	 	 	 	 	 	 	 	 	
THIS SECTION FOR OFFICE USE ONLY - GAMING SECTION	
	Y	N			
Financial Arrangement
Approved			Signature: _____________________________________	
Date___________________	

Gaming Machine Act 2004								
Application for Technical Licence Amendment - Machine Conversion					

										
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 website 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 Mastercard). Please complete the required details in the area 	
 	provided below.	 	 	 	 	 	
										
PAYMENT BY CREDIT CARD	
							Amount
			
Card type	¨ 	Mastercard	¨ 	Visa	$................	(maximum $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)