GAMING MACHINE ACT 2004	
Form made pursuant to Gambling and Racing Control Act 1999, s 53D	
GAMING MACHINE INSTALLATION CERTIFICATE	
	
SECTION 1	DETAILS OF APPLICANT	
Name of Licensee	 	 	
Trading Name	 	 	Licence No.	 	
							
SECTION 2	DETAILS OF SUPPLIER	
Name of Supplier	 	 	
							
SECTION 3	DETAILS OF APPLICATION	
Approval Number	 	Date of Installation	 	Date of last monthly clearance	 	
If there are machines on this approval that have not been installed a list of the serial numbers and expected date of installation is to be forwarded to the Commission.	
	 						
SECTION 4	DETAILS OF EXISTING MACHINES 
DETAILS OF EXISTING MACHINES	
 
 	Machine 1	Machine 2	Machine 3	Machine 4
Machine 5	
Serial Number	 	 		 
 	
Turnover meter	 	 	 	 
 	
Total Wins meter	 	 	 	 
 	
Cashbox meter	 	 	 	 
 	
Credit Pay meter	 	 	 	 
 	
Jackpot meter	 	 	 	 
 	
The following cash values relate to the period from the last monthly clearance until the date of conversion/replacement. 	
Cash in  Hopper $	 	 	 	 
 	
Total Cash Cleared $	 	 	 	 
 	
Short Pays $	 	 	 	 
 	
Refills $	 	 	 	 
 	
Credit Pays $	 	 	 	 
 	
Jackpots $	 	 	 	 

SECTION 5	DETAILS OF NEW MACHINES/ NEW CONFIGURATION	
Serial Number	 	 	 	 
 	
Machine Name	 	 	 	 
 	
%RTP	 	 	 	 
 	
Base Credit Value	 	 	 	 
 	
Link Number	 	 	 	 
 	
Turnover meter	 	 	 	 
 	
Total Wins meter	 	 	 	 
 	
Cashbox meter	 	 	 	 
 	
Credit Pay meter	 	 	 	 
 	
Jackpot meter					
Cash in  Hopper $	 	 	 	 

SECTION 6	DECLARATION	
Pursuant to s45(2) of the Gaming Machine Act 2004 this form must be submitted to the Commission within 3 days of the machine/s	
being installed and the gaming machine/s must not be operated until this notice has been given to the Commission.	 	
 						 	
I certify that the details on this form are true and correct and in accordance with the Commission's approval	
Name of Installing Technician	 	 			Name of Licensee's Representative	 	 	
Certificate Number	 	 			Position	 	 	
Signature 		 	 			Signature	 	 	
Date		 	 			Date	 	 	
 	 	 	 	 	 	 	
AF2009-184	2nd Floor Canberra Nara Centre, 1 Constitution Avenue, Canberra City 2601
PO Box 214 CIVIC SQUARE  ACT  2608
Homepage: http://www.gamblingandracing.act.gov.au