APPLICATION FOR REPOSSESSION OF A 
 GAMING MACHINE 

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

SECTION 1	Details of Organisation Repossessing the Machine(s)
Name	
Address	
Contact Name	
Phone	Fax	Email	

SECTION 2	Premises where the Gaming Machine(s) is currently held
Licensee	
Trading Name	
Address of Premises	
	Block	Section	
Contact Name	Phone	

SECTION 3		Details of Gaming Machine(s) to be Repossessed
Machine Class	Kind of Machine	Stake 
Denomination	Serial 
Number	Manufacturer	

					

					

					

SECTION 4					Fees
See payment options on last page	Total Remittance Due	$	

SECTION 5

Why is the machine(s) being repossessed?

	

Where will the repossessed gaming machine(s) be stored and who will have access to the machine(s)?

	

How do you intend disposing of the repossessed gaming machine(s) eg. auction, direct sale to Manufacturer or ACT licensee, remove from the ACT? (please note that an  “Application for Disposal of a Gaming Machine” (available on the Commission’s website) must be completed and submitted for consideration by the Commission prior to any machine disposals being undertaken).

	

SECTION 6
DOCUMENTION PROVIDING EVIDENCE OF YOUR AUTHORITY TO REPOSSESS THE GAMING MACHINE(S) DETAILED ABOVE MUST ACCOMPANY THIS APPLICATION.

I,________________________________________ of ___________________________________________
                                  (print full name)                                                                   (name of repossessing organisation)

do hereby declare that the information on this application form is true and correct and in accordance with the Gaming Machine Act 2004.

_____________________________        ______________________________      ________/______/______
                     (signature)                                                                      (position)                                                          (date)

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)