AUTHORISATION INSTALLATION CERTIFICATE
With or without gaming machines
Gaming Machine Act 2004

	
SECTION 1	Details of Licensee	
Name of Licensee	 	 	Licence No.		
Authorised Venue	 	 	Cert of Auth No.	 	
							
SECTION 2	Details of Supplier installing gaming machines (if applicable)	
Name of Supplier	 	 	
							
SECTION 3	Details of Notification	
Confirmation Number	 	Date of Installation	 

SECTION 4	Details of authorisations (if machine being acquired with authorisation complete all sections)	
 
 	ID Number		ID Number		ID Number		ID Number		
Serial Number	 	 	 	 
 
 Forfeited authorisation

 

 

 

 

 

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 (technician to complete if gaming machines installed, licensee to complete in all instances)	
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 confirmation of notification.
	
Name of Installing Technician	 	 			Name of Licensee's Representative	 	 	
Certificate Number	 	 			Position	 	 	
Signature 		 	 			Signature	 	 	
Date		 	 			Date	 	 	
 	 	 	 	 	 	 	
AF2015-97