GAMING MACHINE INSTALLATION CERTIFICATE
Conversions and replacements 
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 conversions/replacements	
Name of Supplier	 	 	
							
SECTION 3	Details of Notification	
Confirmation Number	 	Date of Installation	 
 	
If there are machines on this confirmation 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 	
 
 	ID Number		ID Number		ID Number		ID Number		
Serial Number	 	 		 
 	
Turnover meter	 	 	 	 
 	
Total Wins meter	 	 	 	 
 	
Cashbox meter	 	 	 	 
 	
Credit Pay meter	 	 	 	 
 	
Jackpot meter	 	 	 	 
 	
Cash in  Hopper $	 	 	 	 

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	
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	 	 	
 	 	 	 	 	 	 	
AF2015-98