Gaming Machine Act 2004
Sections 84 and 96 

APPLICATION FOR RENEWAL OF 
APPROVED ATTENDANT/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.	Applicant’s 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 record of appointment for fingerprinting with the AFP;
•	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  or DUN & BRADSTREET http://www.dnbcreditreport.com.au).
•	four (4) recent passport photographs with applicant’s name clearly printed on the back;
•	for Attendants a written statement from each licensee/employer stating that the applicant is employed as an Approved Attendant;
•	for Technicians a written statement from each approved supplier/employer stating that the applicant is competent to perform the functions of a Technician and is employed as an Approved Technician OR if in respect of own business a written statement to this effect.

5.	An Approved Attendant/Technician should apply to the Commission for renewal of his or her Certificate (other than a short-term Certificate) NOT LATER THAN 1 MONTH, and not earlier than 3 months, before the Certificate ends.

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

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”)

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

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 Licensee(s)/Supplier(s) with whom you are or will be employed: 

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

Phone:……………………………...  Facsimile:……………..……..…  Certificate Number:…………………………
	
RESIDENCES	
List all addresses at which you have lived during the past 2 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	State/Country	Post Code	
Example
10/10/2005	10/1/2006	ANU – Bruce Hall	Canberra, ACT	0221	
    /    /	Present				
    /    /	    /    /				
    /    /	    /    /				
EMPLOYMENT	
List all work history for the past 2 years include part-time/full-time work, unemployment and schooling.
ACCOUNT FOR ALL PERIODS – dates must be continuous, with no gaps.  	
From	To	Occupation	Employer Name	
Example
10/10/2005	10/1/2006	Student	ANU	
    /    /	Present			
    /    /	    /    /			
    /    /	    /    /			
    /    /	    /    /			

*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).

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.

for 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…...…/….…../………	

Payment details

Important Information
The prescribed fee must accompany an application for an Approved Attendant/Technician Certificate.  Please note that once an application is submitted to the ACT Gambling and Racing Commission the application fee is non-refundable.
The determined fee is available on the Commission 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