APPLICATION FOR TECHNICAL LICENCE AMENDMENT TO
REPLACE A GAMING MACHINE AND DISPOSE OF A GAMING MACHINE
(“TRADE-INS”)

If insufficient space is available for responses please attach additional information.

SECTION 1 			Details of Applicant	
Name of Licensee	
Name of Premises	
Licence No.	
Address	
Contact Name	
Phone	Fax	Email	

SECTION 2 			Installation and disposal details	
Name of Supplier - (Installer) 	
Contact Name	
Phone	Fax	Email	
Is this supplier going to take possession of the machine/s being disposed of? –  YES  /  NO.
If “NO” please provide details of person taking possession of the machine/s.	
Name	
Phone	Fax	Email	

SECTION 3 			Machine details / financial information and fees	
		please provide all machine details on page 2 of this application form 
		and ensure that you complete the financial arrangements on page 3.	

FEES for 
Machine 
Replacements
	See payment options on last page	 No. of 
 Machines	Total Remittance Due	$	

SECTION 4 		

I, ____________________________(print full name) of ___________________________(name of licensee) 

do hereby declare that the information on this application form and the accompanying documentation is true and correct and that all financial arrangements have been declared.

(Signature)______________________(Position)____________________________(Date) _____/____/_____ 	

 	 DETAILS OF MACHINES BEING DISPOSED/REPLACED 		
Licensee:			 	 	 	 	 	 	 	
 	Serial	Machine	Max.	Coin	%	Var.	TICKET	LINK (Yes/No)	LINK %	
 	No.	Name	Coins	Value	Return	No.	YES/NO	APPROVAL No	CONTRIBUTION	
1)  From	  	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
2)  From	  	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
3)  From	  	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
4)  From		 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
5)  From	 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
6)  From	 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
7)  From	  	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
8)  From	  	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
9)  From	 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	
10)  From	 	 	 	 	 	 	 	 	 	
To		 	 	 	 	 	 	 	 	

GAMING MACHINE FINANCIAL ARRANGEMENTS

This form must be completed when Gaming Machines are to be purchased.
A copy of the proposed contract between the Licensee and Supplier for the purchase of any machines must accompany this form.

Licensee:	
Premises Name:	
Contact Name:	
Supplier’s Name:	

Details of the proposed contract for acquisition(including any proposed order) must be attached.

$

TOTAL PURCHASE PRICE (inc GST)             

SOURCE OF FINANCE
1. Cash from licensee’s funds:	$	
    		
    Name of institution where funds are held:		
    Address:		

2. Other source: (Provide details of all relevant financial arrangements, including loans, guarantees, delayed payment plans)

Type of financial agreement:		
Provider of finance:		
Address of provider:		
Duration of Agreement:	Years:	Months:	

Other Details: ______________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________

	OFFICE USE ONLY – GAMING SECTION		
							APPROVAL NUMBER

______________	
APPLICATION	YES		FINANCIAL	YES				
APPROVED	NO		ARRANGEMENT	NO				
			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 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

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