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

APPLICATION FOR MULTI-USER PERMIT TO OPERATE 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 EACH DIRECTOR (For Corporations Only)	
Name	Date of Birth	Address	Position on Board	

				

				

				

				

SECTION 3	DETAILS OF RELEVANT INFLUENTIAL PERSON  (as defined under section 7 of the Act)	
Name	Date of Birth	Address	Relationship to Applicant	

				

				

SECTION 4
SECTION 4	DETAILS OF PROPOSED LINKED LICENSEES  
	
Licensee Name	Licence No.	Address of Premises	

			

			
			
SECTION 5	DOCUMENTS AND INFORMATION THAT MUST ACCOMPANY THIS APPLICATION	
Document/Information required	Gaming Machine Act/Regulation Reference	
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	
Completed Statutory Declaration from each director, executive officer or influential person of the organisation. Available from http://www.legislation.act.gov.au/af/2008-19/default.asp	s 20(1), (3)	
Copies of all contracts in relation to the proposed 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 135(3)(b)(d)
Reg 57
Reg 59
s 135(3)(b)
Reg 60	
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 prospective linked licensee to which the permit will relate – refer section 10 of this form.	s 135(3)(c)	
Particulars of Multi-User Linked Jackpot arrangement - refer section 8 of this form.	s 135(2)	
Copy of Sales Contract or invoice from supplier relating to the purchase of link equipment.	Reg  61(1)	
Financial Particulars for Multi-user Linked Jackpot Arrangement 	Reg  61(1)	
Evidence of jackpot trust account and details of signatories - refer section 9 of this form.	Reg 56	
A copy of the control procedures adopted to control the operation of gaming machines for each proposed linked licensee.	s 135(3)(d)	
SECTION 6	FEES PAYABLE (s135 (1) )	
Total Remittance Due $ 	 	
SECTION 7	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 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 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	

		
SECTION 10	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)