GAMING MACHINE ACT 2004	
Form made pursuant to Gambling and Racing Control Act 1999, s 53D	

   	
    	   
APPLICATION FOR AMENDMENT TO MULTI-USER PERMIT FOR A LINKED JACKPOT ARRANGEMENT

SECTION 1	DETAILS OF APPLICANT	
Name of Applicant	 
	
Trading Name	 
	ABN:	
Street Address	 
	
Postal Address	 
	
Contact Person/s	Phone	Facsimile	Email	

SECTION 2	Details of AMENDMENT REQUESTED	

   √           Tick the type of amendment requested and attach the documents listed below that are outlined in Section 6
	
	Amendment Type	Documents required from Section 6	
	Reduce the number of gaming machines in a linked-jackpot  arrangement	No.2	
	Increase the number of gaming machines in a linked-jackpot arrangement under the permit	No’s 2,3	
	Include a new linked-jackpot arrangement under the permit	No’s 1,2,3,4,5,6,7,8	
	Include gaming machines on other licensed premises in a linked-jackpot arrangement	No’s 1,2,7,8	
	Amend a condition on the permit	Written request.	
	Amend an operational or financial aspect of the linked-jackpot arrangement	No’s 1,3,8	
	Terminate a linked-jackpot arrangement	No’s 2,9	
		
SECTION 3	DETAILS OF PROPOSED LINKED LICENSEES  
	
Licensee Name	Licence No.	Address of Premises	

			

			

			

SECTION 4	FEES PAYABLE (s135 (1) )	
Total Remittance Due 	$ 	

SECTION 5	DECLARATION	
I____________________________________________________of_________________________________________________	
(print full name)                                                                                                                	(name of applicant)	
do hereby apply for a Multi-user Linked Jackpot Permit. I declare that the information on this application form and accompanying documentation is true and correct and that all financial arrangements have been declared.	
 	
Signature____________________________________________________	
 	
Position ____________________________________________________  Date_____/_____/_______

THIS SECTION FOR OFFICE USE ONLY	
 		Yes	No						
Application Fee Paid				________________________	
Application Approved			SIGNATURE: _______________________________	Permit Number	
Financial Arrangement
Approved			DATE: _____________________________________	_____/_______/_________	
 	 	 	Expiry Date	

SECTION 6	DOCUMENTS AND INFORMATION THAT MUST ACCOMPANY THIS APPLICATION	
	
Document No.	Document/Information required	Gaming Machine Act
/Regulation Reference	
1	
Contractual arrangements  between applicant and proposed linked licensees including but not limited to:
- link service fee;
- maximum potential linked jackpot amount
- consent from licensee; and
- collection of linked jackpot contributions.
	s 139(3) 
Reg 57
Reg 59
s 139(3) 
Reg 60	
2	
Details of the class, number, type, coin denomination and percentage payout of gaming machines in relation to which the permit is sought. A separate schedule is required for each licensee to which the permit will relate.
	s 139(3) 	
3	
Particulars of Multi-User Linked Jackpot arrangement – refer section 7 of this form.
	s 139(3)(c)	
4	
Copy of Sales Contract or invoice from supplier relating to the purchase of link equipment.
	Reg 61 (1)	
5	
Financial Particulars for Multi-user Linked Jackpot Arrangement -  refer section 8 of this form.
	Reg 61 (1)	
6	
Details of jackpot trust account and signatories.
	Reg 56	
7	
Rules that the licensee has adopted to control the operation of gaming machines on the licensed premises
	s 11(2)(c); 13(1)(a)	
8	
The control procedures the applicant has adopted to control the operation of gaming machines
	s 11(2)(d); 97	
9	
Written agreement with each person who was a linked licensee about the distribution of the remaining balance of the jackpot trust account
	Reg 62(1)	
SECTION 7	LINK DETAILS (s. 135 (3) (d) )	
Supplier’s Name		
Address		
Name of System		
Specification Number		
Identify Type of Link	CCE	Hyperlink	Normal	
(please tick one)				
Prize Details	Maximum Jackpot $	Reset 
Amount $	Reset Amount %	Contribution %	TOTAL 
%	
Top Jackpot						
Second Jackpot						
Third Jackpot						
Fourth Jackpot						

						
Hidden/Backup						
Total Contribution Percentage						
Other Details	

	
SECTION 8	FINANCIAL PARTICULARS (Reg 61 (1) )	
Details of the invoice or sale contract for acquisition including any proposed order must be attached.	
Total Purchase Price (inc GST)	$	
Source of Finance	

	
1. Cash from Licensees’s funds:	$		
Name of institution 		
Address		
	
2. Other Source	$		
Type of financial agreement*		
Provider of finance		
Address of provider		
Duration of agreement	Years	Months	
*A copy of the financial contract must accompany this application	

		
SECTION 9	MACHINE SELECTION (s. 135 (3) (c) ) – One page to be completed for each proposed linked licensee.	
Licensee:	Licence No:	
 	Serial No	Machine Name	Max. 
Coins	Coin 
Value	% Return to player	Var. No.	 Ticket 
Yes / No	 Link 
Approval No.	Link %
Contribution	
1	To:	 	 	 	 	 	 	 	 	 	
	From:		 	 	 	 	 	 	 	 	
2	To:	 	 	 	 	 	 	 	 	 	
	From:		 	 	 	 	 	 	 	 	
3	To:	 	 	 	 	 	 	 	 	 	
	From:		 	 	 	 	 	 	 	 	
4	To:	 	 	 	 	 	 	 	 	 	
	From:		 	 	 	 	 	 	 	 	
5	To:	 	 	 	 	 	 	 	 	 	
	From:		 	 	 	 	 	 	 	 	
6	To:	 	 	 	 	 	 	 	 	 	
	From:		 	 	 	 	 	 	 	 	
7	To:	 	 	 	 	 	 	 	 	 	
	From:		 	 	 	 	 	 	 	 	
8	From:	 	 	 	 	 	 	 	 	 	
	To:		 	 	 	 	 	 	 	 	
9	To:	 	 	 	 	 	 	 	 	 	
	From:		 	 	 	 	 	 	 	 	
10	To:	 	 	 	 	 	 	 	 	 	
	From:		 	 	 	 	 	 	 	 	

										
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 website 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:	
 									 	
o	money order or cheque made payable to the ACT Gambling and Racing Commission; or	
 									 	
o	credit card (Visa or Mastercard). Please complete the required details in the area provided below.	

PAYMENT BY CREDIT CARD	
							Amount			
Card type	o	Mastercard	o	Visa	$..........................	(maximum $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)