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

APPLICATION FOR APPROVAL OF GAMING MACHINES AND PERIPHERAL EQUIPMENT

SECTION 1	DETAILS OF SUPPLIER	
Name of Supplier		Approval No.		
Postal Address		
Contact Name		Position		
Contact Details	Phone		Fax		Email		

SECTION 2	DETAILS OF GAMING MACHINE or PERIPHERAL EQUIPMENT	
Name of Game / Equipment		
Type of Game / Equipment		
Application Reference Number (ARN)		Specification Number		

SECTION 3	FEES PAYABLE	
Remittance Due	$	For payment options see last page.	

SECTION 4	ADVICE DETAILS	
The approval notification will be forwarded to the person nominated below.	
Name 		Position		
Postal Address		
Contact Details	Phone		Fax		Email		
Preferred delivery method of advice (please tick)	Mail  □    Email  □    Both  □  	

SECTION 5	DECLARATION	

I, _______________________________________________ of ___________________________________________
                                             (print full name)                                                                                                       (name of supplier)

do hereby declare that the information on this application form and accompanying documentation is true and correct.

Signature ________________________________  Position ____________________________ Date_______/______/_______	

This section for office use only – Gaming Regulation	
	Y	N			
Application fee paid					
Technical Evaluation received			  _____________________________	Date: ______/______/________	
Research considered			   Signature of Delegated Officer		
Application approved					
Notified in Legislation Register			   Approval Number NI__________________	Comb. No. ___________________	

AF2011-14
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

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	
										
Card type	o	Mastercard	o	Visa	Amount       $.................................	

										
Card Number      ____ ____ ____ ____    ____ ____ ____ ____   ____ ____ ____ ____   ____ ____ ____ ____  	
								
					Expiry Date	         /          /   		
	
Name on Card:……………………………………………Signature:………………………………………………	

THIS SECTION FOR OFFICE USE ONLY - FINANCE SECTION	
 									 	
Payment Processed by:	…………………………………………	Date	   /       /   	Receipt Number:	……………………..	
 	(Authorised Officer)