Gambling and Racing Control Act 1999, s53D

GAMING MACHINE ACT 2004

	    	   
APPLICATION TO INCREASE THE NUMBER OF GAMING MACHINES - CLUB
(PART 1)

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 Person	Phone	Facsimile	

SECTION 2			MACHINE/MEMBERSHIP INFORMATION
Number of 
Current Machines	Number of 
Additional Machines Requested	Current Membership Numbers 	
Class “B”	Class “C”	Class “B”	Class “C”	Voting	Other	

SECTION 3					FEES
See payment options on last page	Total Remittance Due	$	

SECTION 4           DOCUMENTS AND INFORMATION THAT MUST ACCOMPANY THIS APPLICATION
Documents / Information Required
	Gaming Machine Act/Regulation
 Reference	
Social Impact Assessment. 	s.18 & s. 22(2)(b); Reg. Part 3	
Statement setting out the reasons for the amendment including justification for extra  machines.	s.23(1)(c), 24(3)(b)(iii) 	
Evidence that the majority of voting members voted for the amendment.	s.24(3)(a); Reg. Part 4	
Scale plans/drawings of the premises showing the proposed location/layout of machines.	s.24(3)(b)(i)	
The number of club members worked out in accordance with the Regulations.	s.24(3)(b)(iii); Reg.7	
Information on current level of community contributions and expected contributions for the next 3 years.	s.24(3)(b)(iv)	
Audited financial statements for the three previous financial years.	Reg. 6(2)	
Any relevant new contractual arrangements relating to the use of the premises.	Reg. 6(2)	
Licensees expected revenue and expenditure for the next three years.	Reg. 6(2)	
Any other information that supports your application for the extra machines that complies with the provisions of the Act.	

SECTION 5 
TO BE COMPLETED BY CLUB SECRETARY

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

do 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)

(PART 2)

GAMING MACHINE FINANCIAL ARRANGEMENTS

This Part of the application form is only to be completed if PART 1 has been submitted and additional gaming machines have been approved by the Commission.

Please note 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:	

$

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: ____________________________________________________________________________________________________________________________________________________________
THIS SECTION FOR OFFICE USE ONLY – GAMING SECTION	
							APPROVAL NUMBER

_____________	
APPLICATION	YES		FINANCIAL	YES				
APPROVED	NO		ARRANGEMENT	NO				
			APPROVED				
SIGNATURE:_________________
	DATE:	......../......../........		

 	 DETAILS OF MACHINES BEING ACQUIRED 		
Licensee:			 	 	 	 	 	 	 	
 	Serial	Machine	Max.	Coin	%	Var.	TICKET	LINK (Yes/No)	LINK %	
 	No.	Name	Coins	Value	Return	No.	YES/NO	APPROVAL No	CONTRIBUTION	
1)	  	 	 	 	 	 	 	 	 	
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