STATUTORY DECLARATION
in relation to an
Eligible Person under the Gaming Machine Act 2004

I, (Name)	_______________________________________________________________________________
(Address) of	_______________________________________________________________________________
		__________________________________________	Post Code____________________________
(Occupation) being a_________________________________________________________________________

Pursuant to the Gaming Machine Act 2004 of the Australian Capital Territory, solemnly and sincerely declare that the information provided in this declaration is true in every particular.

Date of Birth:		________________________________________________________________________
Place of Birth:		________________________________________________________________________
Citizenship Status:	_____________________________  If not born in Australia, proof of citizenship must be
                                                                      provided. (eg, naturalisation certificate, passport or certificate as evidence of residence)

Details of convictions or findings of guilt for any offences within the previous 5 years : (If none print NIL)________
____________________________________________________________________________________________________________________

Details of any bankruptcy or any payment arrangement with creditors at any time within the previous 5 years: (If none print NIL)_________________________________________________________________________________
____________________________________________________________________________________________________________________

Details of any corporation in which you were involved in the management of (at any time within the previous 5 years) where the corporation became the subject of a winding-up order or a controller or administrator was appointed (If none print NIL):_______________________________________________________________________

I, make this solemn declaration by virtue of the Statutory Declarations Act 1959 and subject to the penalties provided by that Act for the making of false statements in statutory declarations, conscientiously believe the statements contained in this declaration to be true in every particular.

____________________________________________________
Signature of Applicant

Declared at (place)_______________________________ on (date)_____________________________20_______

before me,

___________________________________________________      _________________________________________________
Signature of Witness				           Title of Witness 
						           (Witness must be an approved person under the
                                                                                                                        Statutory Declarations Act 1959)	
NOTE:   A person who intentionally makes a false statement in a statutory declaration under the Statutory Declarations Act 1959 is guilty of an offence under that Act, the maximum penalty for which is imprisonment for a term not exceeding four years.