APPLICATION TO TRANSFER LICENCE
CLUB

If insufficient space is available for responses please attach additional information

SECTION 1 			Details of Applicant – (Prospective Licensee)	
Name	Address	

	

Phone	
Facsimile	

SECTION 2 	Details of all licences currently held by the applicant under the Act 	
Licence No.	Trading Name	Address	Block 	Section	

					

					

SECTION 3	Details of the licence to be transferred to applicant – (Current Licensee)	
Licence No.	Trading Name	Address	Block 	Section	

SECTION 4 	If the Applicant is a Corporation – Details of each Director of Corporation	
Name	Date of birth	Address	Position on Board	

				

				

				

SECTION 5	Details of relevant influential persons (as defined under section 7 of the Act)	
Name	Date of birth	Address	Relationship to Applicant	

				

SECTION 6	DOCUMENTS AND INFORMATION THAT MUST ACCOMPANY THIS APPLICATION	
Documents/Information	Gaming Machine Act/Regulation Reference	
Alphabetical list of names and addresses of current members of the club, certified correct by the club secretary	s. 11(3)(b)	
Details of any membership sharing arrangements with other licensees	s. 12(5)(c)(i): Reg. 7	
Details of expected community contributions for the current and next 3 financial years	s. 12(5)(c)(iii)	
Declaration relating to club payments and club control (must be made using a statutory declaration)	s. 14	
Prospective licensee must provide evidence that the majority of voting members of the club voted in a ballot for the transfer	s. 32 (1) (d): Reg.-Part 4	
Scale plans of the premises showing proposed gaming area	s. 32(1)(e); 11(2)(b); 13(1)(b)	
Rules that the applicant has adopted to control the operation of gaming machines on the licensed premises	s. 32(1)(e); 11(2)(c); 13(1)(a)	
The control procedures the applicant has adopted to control the operation of gaming machines	s. 32(1)(e); 11(2)(d); 97	
Current licensee must provide evidence that the majority of members of the club voted in a ballot for the transfer of the license	s. 32 (1) (f): Reg.-Part 4	
Signed consent by the current licensee (transferee) to transfer the licence to the prospective licensee (transferor)	s. 31 (2) (c) (i)	
Details of any associated entities	s. 147	
Audited financial statements for the applicant for the previous 3 financial years	Reg. 6(2)	
Contractual arrangements (including proposed arrangements) relating to the proposed premises (eg. a lease)	Reg. 6(2)	
Expected revenue and expenditure for the next 3 years	Reg. 6(2)	

SECTION 7		
TO BE COMPLETED BY CLUB SECRETARY

I,...........................................................................………………………………………………………………..on behalf of the 
	(Print full name)

.........................................…………........................…………………………………………………………………....do hereby 
	(Name of premises)

apply for the Transfer of the Gaming Machine Licence.  I hereby declare that the information on this application form and the accompanying documentation is true and correct.

Signed..........................................................................……………………….....…………….......Date......................………..

(Affix Common Seal)

	
THIS SECTION FOR OFFICE USE ONLY – GAMING SECTION	
APPLICATION FEE PAID	YES	NO	

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 web site 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 Master Card).  Please complete the required details in the area provided below.

Payment by credit card	

Card type	  Master Card	  Visa	    Amount $ ....……..  (maximum of $3,000.00)

Card Number     Expiry Date: .…./….

Name on Card: ……………………………………  Signature: …………………………………..

THIS SECTION FOR OFFICE USE ONLY – FINANCE SECTION

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