STATUTORY DECLARATION
In Relation To An Eligible Person - under the Gaming Machine Act 2004

I, _______________________________________ of __________________________________________________
                                   (name)                                                                                      (address)

__________________Post Code ______________being a ______________________________________________
                                                                                                                               (occupation)

pursuant to the Gaming Machine Act 2004 (the Act) 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)

If you answer YES to any of the following questions, please provide details in the space provided on page 2.

1. Within the last 5 years have you been convicted or found guilty of any offence anywhere?
 YES     NO

2. Within the last 5 years have you been an undischarged bankrupt, applied to take the benefit of a law for the
     relief of bankrupt or insolvent debtors or compounded with creditors or made an assignment of
     remuneration for their benefit?
 YES     NO

3. Within the last 5 years have you been involved in the management of a corporation when it became the
     subject of a winding up order or it had a controller or administrator appointed?
 YES     NO

4. Within the last 12 months have you had a gaming machine licence cancelled (s. 58 of the Act – 
     Disciplinary action)?
 YES     NO

5. Within the last 12 months have you had a gaming machine licence cancelled (s. 64 of the Act - Cancellation of licences because of cancellation etc of general and on liquor licences)?
 YES     NO

6. Within the last 12 months have you had an application for approval as a Supplier refused, on the basis that
    you provided false or misleading information (s. 72 of the Act - Application and approval as Supplier)?
 YES     NO

7. Within the last 12 months have you had an approval as a Supplier cancelled (s.73A of the Act – Cancellation 
     etc of Supplier’s approval)?
 YES     NO

8. Within the last 12 months have you had an application for approval as a Technician refused, on the basis that
    you provided false or misleading information (s. 75 of the Act - Approval of Technicians)?
 YES     NO

9. Within the last 12 months have you had an approval as a Technician cancelled (s. 79(1)(a) or (c) of the Act -  Cancellation etc of Technician’s approval)?
 YES     NO

10. Within the last 12 months have you had an application for approval as an Attendant refused, on the basis
      that you provided false or misleading information (s. 86 of the Act - Approval of Attendants)?
 YES     NO

11. Within the last 12 months have you had an approval as an Attendant cancelled (s. 91(1)(a) or (c) of the Act - 
      Cancellation etc of Attendants approval)?
 YES     NO

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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.

___________________________________Declared at________________________________on_______________
         (Signature of Applicant)                                                                 (place)                                         (date)

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.