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

	  
APPLICATION FOR APPROVAL AS A SUPPLIER

SECTION 1	DETAILS OF APPLICANT	
Name 	 	
A.C.N. (if a Corporation)	 	Registered Address		
Street Address		
Postal Address		
Contact Person/s	Phone	Facsimile	Email	

SECTION 2	DETAILS OF RELEVANT INFLUENTIAL PERSONS  (as defined under section 7 of the Act)	
Name	Relationship to Applicant	Name	Relationship to Applicant	

				

				

SECTION 3	DOCUMENTS AND INFORMATION THAT MUST ACCOMPANY THIS APPLICATION	
Document/Information required	Gaming Machine Act Reference	
Criminal history checks (including fingerprint checks) from the Australian Federal Police covering a period of at least the last five years from each director and influential person (where a person has been domiciled overseas for any length of time during the last five 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. 20(3), 21(1)(a)	
A completed Declaration and Authorisation (refer to page 2 and 3 of this form) for each influential person associated with the applicant.	s. 72(2)(b)(c)	
Documentary evidence that the applicant sells, installs or maintains gaming machines, peripheral equipment for gaming machines or systems (including a CMS) designed for use with gaming machines e.g. a current approval from another Australian jurisdiction.	s. 72(2)(a)	

SECTION 4	FEES PAYABLE 	
Total Remittance Due  	 $	For payment options see last page.	

SECTION 5	DECLARATION	
To be completed by Applicant	
I, __________________________________________________of______________________________________________	
(print full name)                                                                                                                	(name of applicant)	
do hereby apply for approval as a supplier.  I declare that the information on this application form and accompanying documentation is true and correct.	
 	
Signature_________________________________ Position ___________________________  Date_____/_____/_______

THIS SECTION FOR OFFICE USE ONLY 	
Application Fee Paid    Y / N      Application Approved   Y / N       Supplier Number  ___________________________	

Commonwealth of Australia
STATUTORY DECLARATION
Statutory Declarations Act 1959

1	Insert the name, address and occupation of person making the declaration	
I,1

make the following declaration under the Statutory Declarations Act 1959:	

2	Set out matter declared to in numbered paragraphs	
2
If you answer YES to any of the following questions, please provide details in the space provided.

1.	Within the last 5 years have you been convicted or found guilty of any criminal or civil offence anywhere?
	
 YES     NO	

2.	Within the last 5 years have you been an undischarged bankrupt or had obligations under a personal insolvency agreement (including executing such an agreement) or applied to take the benefit of a law for the relief of bankrupt or insolvent debtors?
	
 YES     NO	

3.	Within the last five (5) years have you been involved in the management of a corporation when it became the subject of a winding up order or it had a controller or administrator appointed?
	
 YES     NO	

4.	Within the last 12 months have you had an ACT Gaming Machine Licence or an ACT approval as a Supplier, Technician or Attendant cancelled?
	
 YES     NO	

5.	Within the last 12 months have you had an application for approval as an ACT Supplier, Technician or Attendant refused on the basis that false or misleading information was provided?
	
 YES     NO	

6.	(For Eligible Persons that are corporations) – Is, or has, the corporation been the subject of a winding-up order within the last 3 years?	
 YES     NO	

DETAILS:

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I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular.
	
3	Signature of person making the declaration	3

4	Place
5	Day
6	Month and year	Declared at 4                                            on 5                             of 6  

Before me,
	
7	Signature of person before whom the declaration is made (see over)
	7

8	Full name, qualification and address of person before whom the declaration is made (in printed letters)	8

	
Note 1   A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4 years — see section 11 of the Statutory Declarations Act 1959.
Note 2   Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 — see section 5A of the Statutory Declarations Act 1959.
A statutory declaration under the Statutory Declarations Act 1959 may be made before–
(1) a person who is currently licensed or registered under a law to practise in one of the following occupations:
Chiropractor		Dentist			Legal practitioner
Medical practitioner		Nurse			Optometrist
Patent attorney		Pharmacist			Physiotherapist
Psychologist		Trade marks attorney		Veterinary surgeon
(2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described); or
(3) a person who is in the following list:
Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public
Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)
Bailiff
Bank officer with 5 or more continuous years of service
Building society officer with 5 or more years of continuous service
Chief executive officer of a Commonwealth court
Clerk of a court
Commissioner for Affidavits
Commissioner for Declarations
Credit union officer with 5 or more years of continuous service
Employee of the Australian Trade Commission who is:
(a) in a country or place outside Australia; and
(b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and
(c) exercising his or her function in that place
Employee of the Commonwealth who is:
(a) in a country or place outside Australia; and
(b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and
(c) exercising his or her function in that place
Fellow of the National Tax Accountants’ Association
Finance company officer with 5 or more years of continuous service
Holder of a statutory office not specified in another item in this list
Judge of a court
Justice of the Peace
Magistrate
Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961
Master of a court
Member of Chartered Secretaries Australia
Member of Engineers Australia, other than at the grade of student
Member of the Association of Taxation and Management Accountants
Member of the Australasian Institute of Mining and Metallurgy
Member of the Australian Defence Force who is:
(a) an officer; or
(b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or
(c) a warrant officer within the meaning of that Act
Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants
Member of:
(a) the Parliament of the Commonwealth; or
(b) the Parliament of a State; or
(c) a Territory legislature; or
(d) a local government authority of a State or Territory
Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961
Notary public
Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postal services to the public
Permanent employee of:
(a) the Commonwealth or a Commonwealth authority; or
(b) a State or Territory or a State or Territory authority; or
(c) a local government authority;
with 5 or more years of continuous service who is not specified in another item in this list
Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made
Police officer
Registrar, or Deputy Registrar, of a court
Senior Executive Service employee of:
(a) the Commonwealth or a Commonwealth authority; or
(b) a State or Territory or a State or Territory authority
Sheriff
Sheriff’s officer
Teacher employed on a full-time basis at a school or tertiary education institution

AUTHORISATION

ACT GAMBLING AND RACING COMMISSION
To:	All courts, probation departments, employers - current and previous, educational institutions, legal practitioners, banks, financial and other institutions, all agencies - Federal, State and Local, both foreign and domestic and to whomsoever else this authorisation may be duly presented. 

From:……………………………………………………………………………….........................
 				(print full name)	
of:  ……………………...………………………………………………………………………......
 			(residential or registered address)
Date of Birth:	…….. /...……/…..........                OR              A.C.N.:...............................................
I hereby authorise the ACT Gambling and Racing Commission ("the Commission") and the Australian Federal Police ("the Police") to conduct investigations into my background for the purpose of assessing my suitability as an influential person under the provisions of the Gaming Machine Act 2004. 
I HEREBY AUTHORISE the Commission and the Police to access, inspect and obtain copies of: 
(a) 	any credit report, other report, legal or personal information derived from those reports that has any bearing on my credit worthiness, credit history, credit standing or credit capacity; 
(b) 	any loan information, cheque account records, savings deposit records, safe deposit box records, passbook records and bank statement sheets pertaining to me. 
(c) 	any records relating to investigations of my activities conducted by any State, Territory, Federal or overseas police force, crime investigation agencies, corporate regulatory agencies or any gaming or casino regulatory authorities; 
(d) 	any court records relating to any present or past civil or criminal court proceedings to which I am or was a party; and 
(e) 	any other document, record or correspondence pertaining to me. 
You are HEREBY AUTHORISED to release to the Commission or the Police all the documents, reports, records and information requested by them. 

One of the purposes for which this Authorisation has been given is to satisfy Section 18N(1) (ga(ii)) of the Commonwealth Privacy Act 1988 which provides that a credit provider may only disclose information when the individual concerned has provided written permission. 

Signature of Person: …………………………………..…................................. Date:       /        /					

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 web site 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 Master Card).  Please complete the required details in the area provided below.	

Payment by credit card	

Card type	  Master Card	  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)