Form 3A Gaming Machine Licence Application Category 1 ...

Form 3A
Individual details for a category 1
gaming machine licence (hotel)
Gaming Machine Act 1991 s. 56 • V2 Dec 2013
Office use only
Org no. .................................
App no. ................................
Lic no. ..................................
Site no. ................................
Instructions
This form must accompany Form 3 Application
for a gaming machine licence. Please complete
in BLOCK letters. Attach extra pages if needed. If
you need help completing this form contact the
Office of Liquor and Gaming Regulation (OLGR)
on 13 QGOV (13 74 68).
Note: applicants should be aware that the
Commissioner for Liquor and Gaming has
the legislative ability to require additional
information from an applicant to enable the
Commissioner to make a fully informed decision.
Warning
In accordance with s. 350 of the Gaming
Machine Act 1991, providing false or misleading
information may incur a penalty of 400 penalty
units or two years imprisonment.
Part A—Required documents to be attached to application form at lodgement
Section 1
Document list
FFPersonal probity (short) form
FFminimum of two forms of identification. (Refer to Section 4 of this application)
FFWhere you are acting on behalf of a trust, a copy of the executed trust deed and all
amendments or variations must be provided
FFWhere you are acting on behalf of a trust, all individuals over the age of 18 years, all
beneficiaries in the trust deed must complete a personal probity (short) form
FFWhere the beneficiary of an applicant trust is a company or person / company acting on
behalf of another trust, the following information or documents must also be provided:
a. Copy of a company search, obtained within 14 days of the application being lodged, which
shows the directors, secretary and shareholders of the company
b. Copy of the executed trust deed and all amendments or variations
c. Each company director, secretary and shareholder at a. or beneficiaries of the trust over the age
of 18 at b. must complete a Personal probity (short) form.
FFIndividuals intending to act as the gaming nominee at this premises must undertake the
gaming nominee course and provide a copy of the certificate of competency. This application
can be lodged prior to completion of the course but the certificate must be provided before
the application can be finalised.
Part B—All applicants complete every section
Section 2
Applicant details
Title: Mr Mrs Miss Ms Other.............................................................
Surname ..............................................................................................................................................
First name ............................................................................................................................................
Other name/s .......................................................................................................................................
Date of birth: / /
Place of birth (town/country) ................................................................................................................
Section 3
Aliases
State any aliases (legal or otherwise) which you have used or may have been known by........................
............................................................................................................................................................
e.g. maiden name /previous married name/other christian names should be included.
Office of Liquor and Gaming Regulation Page 1 of 2

Section 4
Address details
Residential address .............................................................................................................................
Locality/suburb.................................................................State
. Postcode
Phone ................................................................. Fax ...........................................................................
Mobile ................................................................ Email ........................................................................
Postal address .....................................................................................................................................
Locality/suburb.................................................................State
.. Postcode
Section 5
Identification
documents
Applicants must provide at least one legible copy of ID from Category A and one other copy of ID from
either Category A or B. ID provided must be current.
Category A
Category B
Driver licence (must provide copy of front and back of
licence if change of address is shown on back)
Australian birth certificate
Australian passport
International birth certificate
International passport
Medicare card
Australian debit or credit card (must provide copy of
front and back of card showing signature)
Government issued identity card with photo
Centrelink pension card
0154LG 2013
OLGR is collecting your personal information in order to assess your application for a gaming machine licence in accordance with s. 56 of the Gaming Machine Act 1991.
OLGR may disclose your personal information to the prescribed entities listed in Schedule 1 of the Gaming Machine Regulation 2002 or as otherwise required by law.
Office of Liquor and Gaming Regulation Page 2 of 2