APPLICATION FOR DISPOSAL OF A GAMING MACHINE	

		If insufficient space is available for responses please attach additional information

SECTION 1				DETAILS OF APPLICANT
Name of Organisation	
Address of Organisation	
Contact Name	
Phone:	Fax:	Email:	

SECTION 2			         DISPOSAL ARRANGEMENTS
Method of proposed disposal:	
Name of person (if any) who is to acquire the Machine/s:	
Address of person who is to acquire the Machine/s:	

SECTION 3			   CURRENT LOCATION OF MACHINE/S 
Address	
Contact Name                                                                                                     Phone:	

SECTION 4		DETAILS OF GAMING MACHINE/S PROPOSED FOR DISPOSAL 
Machine Class	Kind of Machine	Stake Denomination	Serial Number	Manufacturer	

					

SECTION 5					FEES
See payment options on last page	Total Remittance Due	$	

SECTION 6  THE FOLLOWING SUPPORTING DOCUMENTATION IS REQUIRED WITH THIS APPLICATION	
Proof that the person (if any) who is to acquire the machine/s is authorised -
(i)	To operate the machine/s under a licence; or
(ii)	If the machine/s is to be sold or operated in a local jurisdiction – under a law of the local jurisdiction; or
(iii)	Destroy the machine/s.	Gaming Machine Act Reference

113(2)(a)	
For an applicant that has repossessed the machine/s – a copy of the Commission’s Repossession Approval	113(2)(b)	

I,_________________________________________ of ___________________________________________________
                                  (print full name)                                                                                               (name of applicant 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: 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)