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

APPLICATION FOR AUTHORISATION TO OPERATE A	
LINKED-JACKPOT ARRANGEMENT	
	
SECTION 1	DETAILS OF APPLICANT	
Name of Licensee	 	
Trading Name	 	Licence No.	 	
Venue Address	 	
Postal Address	 	
Contact Name	 	
Contact Details	Phone 		Fax		 Email		
		
SECTION 2	DETAILS OF SUPPLIER	
Name of Supplier	 	
Postal Address	 	
Contact Name	 	
Contact Details	Phone 		Fax		 Email		
		
SECTION 3	FEES PAYABLE	
Total Remittance Due 	 $		 For payment options see last page	
		
SECTION 4	DECLARATION	
I, _________________________________________________ of _____________________________________________________	
(print full name)                                                                                                                	(name of licensee)	
do hereby 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 - GAMING SECTION	
 	Yes	No		
APPROVAL NUMBER

___________________	
Application Fee Paid	¨	¨			
Application Approved	¨	¨	SIGNATURE: _______________________________		
Financial Arrangement
Approved	¨	¨	DATE: _____________________________________		

	
AF2009 -186	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

Gaming Machine Act 2004	
Application for Authorisation to Operate a Linked-Jackpot Arrangement	
SECTION 5	LINK DETAILS	
Trading Name		
Supplier’s Name	 	
Address	 	
Name of System	 	
Specification Number	 	Setting or ID No.		
	
Prize Schedule	MAXIMUM JACKPOT
$	RESET AMOUNT

$	RESET AMOUNT 

%	CONTRIBUTION 

%	TOTAL 

%	
Top Jackpot	 	 	 	 	 	
Second Jackpot	 	 	 	 	 	
Third Jackpot	 	 	 	 	 	
Fourth Jackpot	 	 	 	 	 	
Hidden/Backup	 

Total Contribution Percentage	 

 	 	
		
SECTION 6	FINANCIAL ARRANGEMENTS	
Details of the proposed contract for acquisition (including any proposed order) must be attached.	
Total Purchase Price (inc GST)		$	 	
Source of Finance							
1. Cash from licensee's funds:	$			 	
    Name of institution where funds are held:			 	 	
    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.	
										
Other Details:										

 	 	 	 	 	 	 	 	 	 	
THIS SECTION FOR OFFICE USE ONLY - GAMING SECTION	
	Y	N			
Financial Arrangement
Approved			Signature: _____________________________________	
Date_____________________	

Gaming Machine Act 2004								
Application for Authorisation to Operate a Linked-Jackpot Arrangement				

										
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:	 	
 									 	
¨ 	money order or cheque made payable to the ACT Gambling and Racing Commission; or	
 									 	
¨ 	credit card (Visa or Mastercard). Please complete the required details in the area 	 	
 	provided below.	 	 	 	 	 	
										
PAYMENT BY CREDIT CARD	
										
Card type	¨ 	Mastercard	¨ 	Visa	Amount $................	
								(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)