Name of Licensed Premises	
Order Approval Number	Venue Licence Number	
Supplier Name	Date of Installation               /                  /	

OLD MACHINE OR PREVIOUS CONFIGURATION		NEW MACHINE OR NEW CONFIGURATION	
MACHINE NAME			MACHINE NAME		
SERIAL NUMBER			SERIAL NUMBER		
IF ON LINK ARRANGEMENT 
PLEASE PROVIDE LINK
APPROVAL NUMBER			PERCENTAGE RETURN		
			DENOMINATION			
			IF ON LINK ARRANGEMENT 
PLEASE PROVIDE LINK
APPROVAL NUMBER			

OLD MACHINE FINAL READINGS		NEW MACHINE START READINGS	
COINS IN			COINS IN		
COINS OUT			COINS OUT		
COINS/CASH BOX			COINS/CASH BOX		
JACKPOT (MONEY IN)			JACKPOT (MONEY IN)		
CREDIT PAY			CREDIT PAY		
CASH IN HOPPER	$		CASH IN HOPPER	$	

HAS THE ORDER BEEN COMPLETED
YES   /   NO
If no, please list serial numbers of machines not installed
____________________________________________
________________________________________________________________________________________________________________________________________________________________________________________

OLD MACHINE TOTAL CASH FIGURES
(These figures to include all transactions since the last end of month)	
TOTAL CASH CLEARED	$	
JACKPOTS	$	
SHORT PAYS	$	
REFILLS	$	
CREDIT PAYS	
PLEASE NOTE THAT IT IS AN OFFENCE TO: 
•	Install a gaming machine that differs to the Commission’s Order Approval documentation;
•	Install a gaming machine in an area other than an approved gaming area; or
•	Allow unauthorised access to a gaming machine.

$	
TOTAL PAYOUTS	$	
NET RETURN	$	

DATE OF LAST MONTHLY CLEARANCE:              /                  /         	

CERTIFICATION
I certify that the details on this form are true and correct and in accordance with the Commission’s Approval	

Name of Installer  ________________________________________

Technician Certificate No.__________________________________

Signature of Installer______________________________________

Date of signature      ________/_________/________	
Name of Licensee’s 
Representative          __________________________________________

Attendant Certificate No. _______________________________________

Signature of Representative ____________________________________

Date of signature                  _________/_________/_________