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		Phone		
Contact Details	Fax		Email		

SECTION 2	DETAILS OF SUPPLIER	
Name of Supplier		
Postal Address		
Contact Name		Phone		
Contact Details	Fax		Email		

SECTION 3	FEES PAYABLE	
Number 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 Regulation Section	
	Y	N		___________________________________________	
Application Fee Paid			Signature		
Application Approved			Date	__________________	Approval Number	____________	
Financial Arrangements Approved							

AF2011-18
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

SECTION 5	MACHINE SELECTION SCHEDULE	
GAMING MACHINE 1	
New Machine Details	
Serial Number	Machine Name	RTP %	BCV	Link %	
					
Specification No.	Platform/Cabinet	Var No.	Ticket Out	Link Number*	
			Y/N		
Existing Machine Details	
Serial Number	Machine Name	RTP %	BCV	Link Number*	

GAMING MACHINE 2	
New Machine Details	
Serial Number	Machine Name	RTP %	BCV	Link %	
					
Specification No.	Platform/Cabinet	Var No.	Ticket Out	Link Number*	
			Y/N		
Existing Machine Details	
Serial Number	Machine Name	RTP %	BCV	Link Number*	

GAMING MACHINE 3	
New Machine Details	
Serial Number	Machine Name	RTP %	BCV	Link %	
					
Specification No.	Platform/Cabinet	Var No.	Ticket Out	Link Number*	
			Y/N		
Existing Machine Details	
Serial Number	Machine Name	RTP %	BCV	Link Number*	

GAMING MACHINE 4	
New Machine Details	
Serial Number	Machine Name	RTP %	BCV	Link %	
					
Specification No.	Platform/Cabinet	Var No.	Ticket Out	Link Number*	
			Y/N		
Existing Machine Details	
Serial Number	Machine Name	RTP %	BCV	Link Number*	
					
*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.

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 applying in respect of the converted gaming machine.

	Y	N	
Will an IP licence apply to any of the converted gaming machines?  
If yes a copy of the proposed contract must be submitted with this application.			
 
Total Purchase Price of Conversion/s (inc. GST). 
A copy of the sales order/invoice must accompany this application.	$	
Source of Finance	
1.	Cash from licensee’s funds	$		
Name of institution where funds are held		
Address of financial institution		
	
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 Regulation Section	
	Y	N					
Financial Arrangement Approved?			Signature	____________________________________	Date	_______________	

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:	
 									 	
o	money order or cheque made payable to the ACT Gambling and Racing Commission; or	
 									 	
o	credit card (Visa or Mastercard). Please complete the required details in the area provided below 	

PAYMENT BY CREDIT CARD	
										
Card type	o	Mastercard	o	Visa	Amount          $................................	

										
Card Number      ____ ____ ____ ____    ____ ____ ____ ____   ____ ____ ____ ____   ____ ____ ____ ____  	
								
					Expiry Date	         /          /   		
	
Name on Card:……………………………………………Signature:………………………………………………	

THIS SECTION FOR OFFICE USE ONLY - FINANCE SECTION	
 									 	
Payment Processed by:	…………………………………………	Date	    /     /   	Receipt Number:	……………………..	
 	(Authorised Officer)