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

   	    	   
APPLICATION FOR TRANSFER OF A MULTI-USER PERMIT FOR A LINKED JACKPOT ARRANGEMENT

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

SECTION 2	DETAILS OF TRANSFEROR	
Name of Applicant	 
	
Trading Name	 
	ABN:	
Street Address	 
	
Postal Address	 
	
Contact Person/s	Phone	Facsimile	Email	

SECTION 3	DETAILS OF EACH DIRECTOR (For Corporations Only) 	
Name	Date of birth	Address	Position on Board	

				

				

				

				

SECTION 4	Details of relevant influential persons (as defined under section 7 of the Act)	
Name	Date of birth	Address	Relationship to Applicant	

				

SECTION 5	DOCUMENTS AND INFORMATION THAT MUST ACCOMPANY THIS APPLICATION	
Document/Information required	Gaming Machine Act/
Regulation Reference	
For Non- Club Applicants			
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 12(2)(a); 20, 21	
All applicants			
Copy of all contracts relating to the transfer of the Permit to operate a linked-jackpot arrangement	Reg 61 (1)	
Completed Statutory Declaration included as part of this application form for each director, executive officer or influential person of the organisation. .	s 20(1), (3)	
Copy of all 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	
Details of jackpot trust account and signatories	Reg 56	
	
SECTION 6	FEES PAYABLE (s135 (1) )	
Total Remittance Due 	$ 	

SECTION 7	DECLARATION BY TRANSFEREE	
I____________________________________________________of_________________________________________________	
(print full name)                                                                                                                	(name of applicant)	
do hereby apply for the transfer of Multi-user Linked Jackpot Permit number MU    /          .  I declare that the information on this application form and the accompanying documentation is true and correct and that all financial arrangements have been declared.	
Signature____________________________________________________	
 	
Position ____________________________________________________  Date_____/_____/_______

SECTION 8	DECLARATION BY TRANSFEROR	
I,                                                                                                             of 	
(print full name)                                                                                                                	(name of applicant)	
do hereby agree to transfer Multi-user Linked Jackpot Permit number MU../……… to the applicant.	
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 9	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	

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)