Gambling and Racing Control Act 1999, s 53D

GAMING MACHINE ACT 2004

	    	   
APPLICATION FOR APPROVAL AS A SUPPLIER

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

SECTION 1 				Details of Applicant 	
Name		
Address		
A.C.N (if a Corporation)		
Registered Office		
Contact Person		Phone		
Email		Fax		

SECTION 2	Details of each executive officer and influential person of a corporate applicant
(as defined under section 7 of the Act)	
Name	Date of birth	Address	Relationship to Applicant	

				

SECTION 3	DOCUMENTS AND INFORMATION THAT MUST ACCOMPANY THIS APPLICATION	
Document/Information required	Gaming Machine Act or Regulation Reference	
Criminal history checks (including fingerprint checks) from the Australian Federal Police covering a period of at least the last five years from each director, executive officer and influential person (where a person has been domiciled overseas for any length of time during the last 5 years that person will also need to provide a criminal history check from the national law enforcement agency of the nation in which the person was domiciled).	s.20(3),21(1)(a)	
A copy of the business’s most recent audited financial statements.	s.72	
Completed Statutory Declaration included as part of this application form for influential person associated with the applicant.	s.72(2)(b)(c)	

SECTION 4		
TO BE COMPLETED BY APPLICANT

I,...............................................................………………………………………………..………..do hereby declare
                                                                           (Print full name)
that the information on this application form and the accompanying documentation is true and correct.

Signed.............………………………………………………………................................Date......................……….

(Corporate Applicants to Affix Common Seal)

THIS SECTION FOR OFFICE USE ONLY – GAMING SECTION	
APPLICATION FEE PAID	YES	NO	

STATUTORY DECLARATION
in relation to an
Eligible Person under the Gaming Machine Act 2004

I, (Name)	_______________________________________________________________________________
(Address) of	_______________________________________________________________________________
		__________________________________________	Post Code____________________________
(Occupation) being a_________________________________________________________________________

Pursuant to the Gaming Machine Act 2004 of the Australian Capital Territory, solemnly and sincerely declare that the information provided in this declaration is true in every particular.

Date of Birth:		________________________________________________________________________
Place of Birth:		________________________________________________________________________
Citizenship Status:	_____________________________  If not born in Australia, proof of citizenship must be
                                                                      provided. (eg, naturalisation certificate, passport or certificate as evidence of residence)

Details of convictions or findings of guilt for any offences within the previous 5 years : (If none print NIL)________
____________________________________________________________________________________________________________________

Details of any bankruptcy or any payment arrangement with creditors at any time within the previous 5 years: (If none print NIL)_________________________________________________________________________________
____________________________________________________________________________________________________________________

Details of any corporation in which you were involved in the management of (at any time within the previous 5 years) where the corporation became the subject of a winding-up order or a controller or administrator was appointed (If none print NIL):_______________________________________________________________________

I, make this solemn declaration by virtue of the Statutory Declarations Act 1959 and subject to the penalties provided by that Act for the making of false statements in statutory declarations, conscientiously believe the statements contained in this declaration to be true in every particular.

____________________________________________________
Signature of Applicant

Declared at (place)_______________________________ on (date)_____________________________20_______

before me,

___________________________________________________      _________________________________________________
Signature of Witness				           Title of Witness 
						           (Witness must be an approved person under the
                                                                                                                        Statutory Declarations Act 1959)	
NOTE:   A person who intentionally makes a false statement in a statutory declaration under the Statutory Declarations Act 1959 is guilty of an offence under that Act, the maximum penalty for which is imprisonment for a term not exceeding four years.	

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)