APPLICATION TO TRANSFER LICENCE
HOTEL/TAVERN

Applicant must have held a general or on liquor licence for a continuous period of 1 year before the day of this application.  If insufficient space is available for responses please attach additional information.

SECTION 1 				Details of Applicant 	

(a)	“Corporate Applicant”

Name of Corporation	Registered Office/Address	
		
(Please provide copy of Certificate of Incorporation)	
Contact Person
	Phone	Facsimile	

(b)	“Partnership or Sole Proprietor Applicant”

Name of each Person	Address	

		
		
Contact Person
	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 & INFORMATION THAT MUST ACCOMPANY THIS APPLICATION	
Documents/Information	Gaming Machine Act/Regulation Reference	

Signed consent by the current licensee (transferee) to transfer the licence to the prospective licensee (transferor)	s.31 (2) (c) (i)	
Audited financial statements in respect of any business operated by 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)	
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	
Criminal history checks (including fingerprint checks) from the Australian federal police covering a period of at least the last five years from each executive officer and influential person (where a person has been domiciled overseas for any length of time during the last 5 years that person will also need to provide a criminal history check from the national law enforcement agency of the nation in which the person was domiciled)	s.32(1)(e); 12(2)(a); 20, 21	
Declaration that the premises are used primarily for the consumption of alcohol	s.13(1)(d)	
Applicants for a General licence with more than two (2) Class “B” gaming machines must provide evidence that the premises has a minimum of 12 rooms of accommodation	s.16	
Evidence of date and issue of liquor licence	s.20(2)(a)(ii); 21(1)(c)	
Declaration (if a corporate applicant) that the corporation is not and has not been the subject of a winding-up order or had a controller or administrator appointed in the last 3 years.	s.21(1)(d)&(e)	

SECTION 7 		
TO BE COMPLETED BY APPLICANT

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 www.gamblingandracing.act.gov.au  otherwise, 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)