Gaming Machine Act 2004
Sections 89 and 78
APPLICATION TO TRANSFER/AMEND 
APPROVED ATTENDANT/TECHNICIAN CERTIFICATE

When lodging this application with the ACT Gambling and Racing Commission (the Commission) ensure that you have:
•	completed the application in full and attached any required documentation;
•	attached the original Certificate (plus ID card for Technicians) that you are applying to have amended or a Statutory Declaration stating why the Certificate cannot be produced;
•	included payment of the prescribed fee for application processing.

PERSONAL DETAILS	
	Mr/Mrs/Miss/Ms (Circle) 
 …………………………………………………………..………………………..…….
		  Surname 			    Given Name 			Middle Name/s

Date of Birth:          /          /         	Telephone/Mobile: ……………………………………….
	
Residential address 
………………………………………………………………………………………….
		Street 						Suburb

……………………………………………………….…………………………………
		State 						Postcode
	
CERTIFICATE INFORMATION & REQUIRED DOCUMENTATION	
Current Certificate Number: 				
•	transfer my certificate to a new licensee/supplier 
I request that the Commission transfer my Attendant/Technician Certificate to the following Licensees/Suppliers: ………………………………………………………………………………………...…..
•	add an additional licensee/supplier to my existing certificate
I request that the Commission amend my Attendant/Technician Certificate to add the following Licensees/Suppliers: …………………………………………………………………...………………………..
The following documentation is required to be attached when applying for either of the above amendments: A statement from each licensee/supplier who employs, or has offered to employ, the applicant as an Attendant/Technician and Technicians also require a statement of competency from their employer(s).

•	remove a licensee/supplier from my existing certificate 
I request that the Commission amend my Attendant/Technician Certificate and remove the following Licensees/Suppliers: ……………………………………………………………………………………..……..
Signature of Applicant:…………………..…..Date:         /         /       	
APPLICATION FEE PAID	YES	NO	

Delegate of the Commission  ……………………………………………….…  Date….…/……../……	

Payment details

Important Information
The prescribed fee must accompany an application for an amendment to an Approved Attendant/Technician Certificate.  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 website: http://www.gamblingandracing.act.gov.au/TheCommission/Fees.htm  
Otherwise, contact the Commission on 6207 0359.	

Please indicate the method of payment:
•	money order or cheque made payable to the ACT Gambling and Racing Commission;
•	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)
Card Number: _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _ Expiry Date: __/__
Name on Card: ……………………………………….….   Signature: ……………………………………..

This section for office use only

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