Form 2 Application for Eligibility Certificate by a Corporation (PDF ...

Form 2
August 2008
CONFIDENTIAL
Racing Act 2002
(Section 207)
Application For Eligibility Certificate
By A Corporation
___________________________________________________________________________
(Name of Applicant Corporation)
hereby makes application for an eligibility certificate under Section 207 of the Racing Act
2002.
The application form has been completed in full and the applicable application fee is attached.
Signature of Authorised Executive Officer: __________________ Date: ____ /____ /____
Office of Liquor, Gaming and Racing

Version:
August 2008
COMPANY PROBITY FORM
This form is used to assist the completion of suitability checks performed on certain
companies that are or are associated with a Gaming Applicant/Licensee in Queensland
CONFIDENTIAL
Company to which this form relates:
This form has been submitted for the purpose of:
(e.g. “Application for Suppliers Licence under the Gaming Machine Act 1991”)
Name of Gaming Applicant/Licensee:
Note: This form should be completed in every particular. Incomplete forms may be returned
for completion. This may result in delays in the probity process and, if applicable, the
consideration of any licence application.
Queensland Office of Liquor, Gaming and Racing
Locked Bag 180
CITY EAST QLD 4002
AUSTRALIA
Telephone: (07) 3872 0852; Fax: (07) 3872 0951

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
IMPORTANT
WARNING
ABOUT FALSE OR MISLEADING INFORMATION
OR INCOMPLETE DISCLOSURE
Applicants and other persons completing this form should be aware
that action may be taken should information be supplied that is
false, misleading or incomplete in a material particular.
Persons who submit false or misleading information may be
prosecuted and fined.
Where a licence is issued and it is subsequently found that full
disclosures had not been made in relation to the licensee or its
associates or that false or misleading information had been
provided, show cause action may be taken. That action would
determine whether the licence should be cancelled or suspended.
INSTRUCTIONS TO BE READ
It is critical that the Instructions for Completion contained on pages
4 and 5 are read fully before this form is completed.
Signature: ___________________________________ 3

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
INSTRUCTIONS FOR COMPLETION
1. The Company Probity Form must be completed by:
• the Principal Executive Officer; or
• if the Principal Executive Officer does not have knowledge of the relevant facts,
another person who has the knowledge and is authorised by the company to
complete this form and which authority has been minuted.
2. Type or print in BLOCK LETTERS an answer to every question.
3. If an electronic version of this form is being completed, information supplied in
response to a question may be inserted but no question, or the order of questions, is to
be altered.
4. If a question does not apply to the company state “N/A” in response to that question.
5. If there is nothing to disclose in reply to a particular question state “Nil” in response to
that question.
6. If there is insufficient space on a printed form in which to answer a question, additional
information may be provided on an attachment page. When required to use an
attachment page precede each answer thereon with the title applicable to that question
and PRINT the company name on the page.
7. All dates should be completed in the form: Day / Month / Year.
8. Each page of this form and each attached page should be signed by the person
completing the form in the space provided.
9. This form is to be completed in the English language. Any documents required to be
provided are to have a certified English translation appended.
10. Documents or other information sought from authorities in Australia may not be
applicable to a company which has been incorporated in another country or which
originates from a company located overseas. In such cases the documents or equivalent
information should be obtained from the relevant authority of that country.
11. An asterisk (*) signifies “Delete whichever is not applicable”.
Signature: ___________________________________ 4

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
12. The completed form should be forwarded to:
The Executive Director
Office of Liquor, Gaming and Racing
Locked Bag 180
CITY EAST QLD 4002
AUSTRALIA
13. This form should be sealed in an envelope and marked:
“Private and Confidential
Attention: Executive Director, Office of Liquor, Gaming and Racing”.
14. Any further inquiries should be directed to the Probity Section, Office of Liquor,
Gaming and Racing, telephone (07) 3872 0852. (For calls outside Australia, the number
is 61 7 3872 0852.)
15. Note: A reference to a corporation includes a person.
16. Persons completing this form may require to be interviewed by officers of the
Office of Liquor, Gaming and Racing on one or more occasions. If you are required
to be interviewed the place and form of the interview will be at the discretion of the
Office of Liquor, Gaming and Racing. All persons to be interviewed are required to
bear their own cost of travel and accommodation, if applicable.
17. Persons completing this form should be aware that probity investigations will not be
commenced until required information is provided. In addition, a probity investigation
may be halted where additional information sought is not provided in a timely manner.
Acts administered by the Office of Liquor, Gaming and Racing also allow for
penalties to be imposed for the failure to supply information.
Signature: ___________________________________ 5

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
CERTIFICATE
I, ________________________________________________________________________________________
hereby declare as follows:
(a)
I hold the position of __________________________________________________________________
in _________________________________________________________________________________
(name of corporation)
and am duly authorised to complete this form (authority to complete should be minuted).
(b)
I certify that the particulars contained herein are true and correct in every detail and fully disclose the
information required to complete this form.
SIGNED at _____________________this___________________ day of _______________________20 ____
______________________________
(Signature)
In the presence of:
______________________________
(Signature of Witness)
Name of Witness:
Address of Witness:
_______________________________________________________________________
_______________________________________________________________________
Telephone Number of Witness: ( ___ ) _____________________
ACKNOWLEDGEMENT AND UNDERTAKING
The company undertakes to supply the following information if requested to do so:
(a) copies of income tax returns and tax assessments;
(b) copies of minutes of shareholder and director meetings;
(c) explanations relevant to the published financial statements;
(d) copies of the company’s shareholder register.
The company notes and acknowledges that the information requested in this Company Probity Form may not
satisfy the probity requirements of the Office of Liquor, Gaming and Racing and that further information
may be requested.
Signature: ___________________________________ 6

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
AUTHORITY FOR RELEASE OF INFORMATION BY A CORPORATION
__________________________________________________________________________________
(name of corporation)
of ______________________________________________________________________________
(address)
hereinafter referred to as “the Corporation”:
1. acknowledges that the Casino Control Act 1982, the Gaming Machine Act 1991, the Keno Act
1996, the Lotteries Act 1997, the Interactive Gambling (Player Protection) Act 1998 Racing
Act 2002 and/or the Wagering Act 1998 (“the Acts”) authorises the Treasurer and/or Under
Treasurer of the State of Queensland (a State of Australia) to cause to be made investigations
about the Corporation for the purposes of determining the Corporation’s suitability for the
purposes of the Acts;
2. authorises the Treasurer, Under Treasurer and any person conducting any investigations or
enquires on behalf of the Treasurer or Under Treasurer for the purposes of the Acts, including
any officer of the Office of Liquor Gaming and Racing (“Authorised Person”), to obtain
any information and make any investigations or enquiries which relate to the Corporation and
may be relevant to any of the purposes of the Act, in any jurisdiction;
3. authorises an officer of the Australian Taxation Office, the manager or other principal officer of
any branch or office of a bank or financial institution in any jurisdiction to whom a copy of this
authority is presented to allow any Authorised Person to inspect and obtain copies of, or to
release to any Authorised Person, any record, document or other information of any kind in
written, electronic or any other form, which relates to the Corporation and is held by the
Australian Taxation Office, bank or financial institution; and
4. authorises any officer of any police service, law enforcement agency or regulatory body in any
jurisdiction to whom a copy of this authority is presented to release to any Authorised Person
any information or official record of any kind in written, electronic or any other form, which
relates to the Corporation and is held by the police service, agency or body, including any
information relating to the criminal history of the Corporation.
The Corporation undertakes that it will at all times sufficiently indemnify those officers referred to in
“3” and “4” above and the Authorised Person and keep those officers referred to in “3” and “4” above
and the Authorised Person indemnified against all liability in respect of the supply or disclosure in
accordance with the Acts, of the information, and against all actions, suits, proceedings, claims,
demands, costs and expenses whatsoever which may be taken against those officers referred to in “3”
and “4” above and the Authorised Person or incurred or become payable by those officers referred to
in “3” and “4” above or the Authorised Person in respect thereof.
SIGNED under the Common Seal this ________________ day of _____________________ 20 _____
Seal affixed by:
_____________________________
(Signature of authorised person)
_____________________________
(Name and position)
_____________________________
(Signature of authorised person)
_____________________________
(Name and position)
Signature: ___________________________________ 7

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
COMPANYETAILS – PART ONE
Information to be provided by way of attachments
The following attachments must accompany this form:
A. A brief history of the company (not required if a current licensee).
(This should include details of the original purpose and business of the company, the
names of the founders and what funds were initially injected and by whom.)
B. A “Statement of Company Records” to be prepared and signed by a Certified Practising
Accountant (CPA) or a qualified company auditor.
(This statement should –
(i)
(ii)
certify that the company’s records are up to date and, where applicable, in
agreement with Australian Securities and Investments Commission (ASIC)
records [or equivalent]. Company records include such records as share
registers, Company Constitution or equivalent, register of directors, secretaries
and managers, minutes of company meetings, financial reports, annual returns;
and
identify tax returns due and outstanding.)
C. A flow-chart supported by written text explaining the corporate structure in which the
company exists.
(Details should include the shareholding, the principal business and the names and
addresses of the directors of each company within the corporate structure.)
D. A list of companies in which any company identified in the corporate structure flowchart
holds greater or is able to exert influence over greater than 15% of the issued share
capital (if none, advise accordingly).
E. A description of the largest 20 shareholders of the company.
(Details should show the full name of each shareholder and the relevant number and
percentage of shares held.)
F. A copy of the current Company Constitution or equivalent.
G. Copies of the Certificate of Incorporation and each Certificate of Change of Name of
Company.
H. Copies of the financial statements for the company and any holding company, for the
last five (5) years. Copies of audited accounts should be provided, if applicable.
Signature: ___________________________________ 8

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
I. A copy of the Annual Reports of the company for the last five (5) years, if applicable.
If not applicable, provide reasons.
J. A copy of the company’s Chart of Accounts.
Signature: ___________________________________ 9

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
A. COMPANY DETAILS
PART TWO
Information to be provided by written answer
(i)
Full name of company as currently incorporated:
________________________________________________________________
(ii)
Other names the company has been known by:
________________________________________________________________
________________________________________________________________
________________________________________________________________
(iii)
Registered office: _________________________________________________
________________________________________________________________
(iv)
Address of principal place of business:
________________________________________________________________
________________________________________________________________
Number of years at this address: ___________
(v)
Postal address: ___________________________________________________
________________________________________________________________
(vi)
Contact Details:
Telephones – Business: ( ____ ) __________________
After Hours: ( ____ ) __________________
Mobile:
_________________________
Email:
_____________________________________
(vii)
Preferred contact person: ___________________________________________
(viii) Date of incorporation: _____ / _____ / _____
Signature: ___________________________________ 10

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
(ix)
(x)
Place of incorporation: _____________________________________________
Australian Company Number (ACN): _________________________________
(or equivalent – please specify).
(xi)
(xii)
Paid Up Capital: $ ________________
Name of the ultimate holding entity of the company:
________________________________________________________________
(xiii) List the following details for each current director, company secretary and any
other officeholder (including members of the management board, supervisory
board or any other body, by whatever name called) as well as the Chief
Executive Officer:
Name Position Residential Address
Place and
Date of Birth
(xiv) List the following details for each director and other officeholder who has
ceased to hold office during the last five (5) years:
Name
Last known residential address
Date of
Cessation
Signature: ___________________________________ 11

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
(xv)
Apart from those identified in Questions (xiii) and (xiv) above and the 20 largest
shareholders (as advised by attachment – see Part One, item “E”), does any
person or organisation either directly or indirectly have a controlling interest or
significant influence in the company? (This may include but is not limited to a
finance provider.)
* YES / NO
If YES, please provide details:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(xvi) Does the company have any other company or person acting on its behalf in
Australia or overseas?
* YES / NO
If YES, provide full details:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(xvii) List all trading names and trademarks under which the company, its holding
company and subsidiaries of the holding company operate.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature: ___________________________________ 12

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
(xviii) Is the company a trustee of any trust?
* YES / NO
If YES, provide full details:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(xix) Is the company or the ultimate holding entity of the company listed on the
Australian Stock Exchange (or overseas equivalent)?
* YES / NO
If YES, has the listed company every been fined, suspended or reprimanded for
breaches of the Australian Stock Exchange (or overseas equivalent) listing rules?
If YES, provide full details:
* YES / NO
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(xx)
List the following details for each company auditor and external accountant
engaged over the last five (5) years:
Firm/Company
Address
Period of
Engagement
Signature: ___________________________________ 13

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
(xxi) To your knowledge while engaged by the company did such auditors or external
accountants become subject to investigation for any reason?
* YES / NO
If YES, provide full details:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(xxii) List the following details of any legal advisers, solicitors and/or consultants
engaged over the last five (5) years:
Firm/Company
Address
Period and Capacity
of Engagement
(xxiii) Commencing with the current state and country and working backwards, list all
the states and countries in which the company has conducted business over the
last 20 years.
State and Country
Dates Business Conducted
From
To
Signature: ___________________________________ 14

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
B. ARRESTS, DETENTIONS AND LITIGATION
Please note that disclosure of these matters in respect to a conviction or charge under
a Queensland law for both the company and the individual is not limited by any time
frame.
(i)
Has the company, or any holding or subsidiary company, in Australia or
elsewhere:
(a) been convicted of an offence? * YES / NO
(b) been investigated by a law enforcement agency? * YES / NO
(c) been summoned before a court to answer any offence? * YES / NO
If YES, provide full details:
________________________________________________________________
________________________________________________________________
________________________________________________________________
(ii)
Has any office holder or employee of the company, acting in that capacity, in
Australia or elsewhere:
(a) been convicted of an offence? * YES / NO
(b) been investigated by a law enforcement agency? * YES / NO
(c) been charged by a law enforcement agency? * YES / NO
(d)
(e)
been summoned before a court to answer any offence whatsoever?
* YES / NO
had any charge proven without the recording of a conviction? * YES / NO
(f) had civil proceedings instituted against them? * YES / NO
If YES, provide full details: _________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature: ___________________________________ 15

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
The Criminal Law (Rehabilitation of Offenders) Act 1986 of Queensland
does not apply as Acts administered by OLGR are exempt. However, you may
be entitled to claim a right of non-disclosure of matters arising under federal
law or laws in other jurisdictions other than Queensland.
If you have any concerns in that regard you should contact either:
• the Privacy Commissioner (Federal) on the Privacy Hotline 1300 363 992;
or
• the equivalent body in your State; or
• your solicitor.
Note: “Law enforcement agency” includes but is not limited to State, Federal and Overseas
Agencies such as Police Services, Crime Authorities, Crime Commissions, Commissions against
Corruption, Securities and Investments Commissions, Customs Services, Taxation Offices,
Competition and Consumer Commissions and Gaming Authorities.
Note: If you are seeking entitlement to non-disclosure and will not be
answering the above questions please place a cross in the box. An attachment
setting out the reasons for non-disclosure including copies of the relevant
legislation should accompany this form.
(iii)
Has the company or any holding or subsidiary company been the subject of any
investigation by any government authority, i.e. by any State or Commonwealth
authority or department (or by any overseas equivalent)?
* YES / NO
If YES, please provide details: ______________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(iv)
Has the company or any holding or subsidiary company had civil proceedings
against it and is there any significant litigation currently in progress or pending?
* YES / NO
If YES, please provide details: ______________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature: ___________________________________ 16

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
(v)
Has the company or any holding or subsidiary company ever had any licence,
certificate, authority or approval issued by a government agency in Australia or
elsewhere relating to the conduct of gaming or any other business terminated,
denied, suspended or revoked?
* YES / NO
If YES, please provide details: ______________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
C. FINANCIAL
(i)
List the following details of any persons, companies or institutions from which
the company has current loans or has obtained funds on loan during the last
five (5) years.
(All amounts to be shown in Australian dollars)
Name of Lender
Amount
borrowed
(A$)
Purpose of
Loan
Date of
Commencement
Expected
Final
Repayment
Date
Secured/
Unsecured
(ii) Is there any relationship between the company and the lender? * YES / NO
If YES, provide full details: _________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature: ___________________________________ 17

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
(iii)
Has there been any material change to the financial situation of the company or
its holding company since the last accounts for the company were made up
which could impact upon the company’s operations?
* YES / NO
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(iv)
List the following details of all bank accounts operated by the company:
Account Name
Purpose of Loan
Bank, Branch and
Country
Account
Number
(v)
List the following details for each investment which currently represents greater
than 5% of the company’s total assets:
Description of Investment
Percentage of
Total Assets
Signature: ___________________________________ 18

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
(vi)
Has the company or any holding or subsidiary company:
(a)
(b)
(c)
been placed into liquidation, receivership, scheme of arrangement or under
other formal insolvency administration;
had an agent for the mortgagee appointed; or
had an investigation into the affairs of the company authorised under the
Australian Securities and Investments Commission, its predecessors or
equivalent overseas body?
* YES / NO
If YES, complete the following:
Type of proceedings: _________________________________________
Commencement date: _____ / _____ / _____
Company name: _____________________________________________
Name of Trustee, Administrator, Liquidator or Receiver/Manager:
___________________________________________________________
Telephone: ( ___ ) _______________________
Details of circumstances leading to proceedings (including details of any
pending arrangements) and a copy of the external administrator’s report
should be attached if available:
___________________________________________________________
___________________________________________________________
___________________________________________________________
(vii)
Are there any outstanding claims or litigation which could adversely affect the
financial viability of the company?
* YES / NO
If YES, please provide details: ______________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(viii) If applying for a licence, advise whether the licence will be placed as collateral
against any indebtedness.
Signature: ___________________________________ 19

Office of Liquor, Gaming and Racing
MPANY PROBITY FORM
* YES / NO
If YES, please provide details:
________________________________________________________________
________________________________________________________________
________________________________________________________________
(ix)
Is the company and any holding or subsidiary company up to date with taxation
lodgements?
* YES / NO
If NO, please provide reasons: _______________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(x)
Is the company or any holding or subsidiary company, or a director of the
company or any holding or subsidiary company, being investigated by any
taxation authority in any country?
* YES / NO
If YES, please provide details: ______________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(xi)
Has the company or any holding or subsidiary company, or a director of the
company or any holding or subsidiary company, been investigated by any
taxation authority in any country?
* YES / NO
If YES, please provide details: ______________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature: ___________________________________ 20

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
D. INVOLVEMENT IN GAMING
(i)
Prior to this date has the company, any holding company or other related body
corporate, been associated with the ownership, administration or management
of:
(a) a casino;
(b) keno or lottery operations;
(c) interactive gambling;
(d) race wagering or sports wagering operations (including bookmaking);
(e)
(f)
(g)
club, hotel or tavern;
the manufacture, assembling, selling, distributing, importing, supplying,
repairing or operation of gaming machines, in-line machines, lucky
envelope machines or other amusement devices;
a licensed monitoring operator.
* YES / NO
If YES, please provide details: ______________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature: ___________________________________ 21

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
(ii)
Has the company, any holding company or other related body corporate had any
interest, financial or otherwise, in any other company or with any person or
business that is involved with the ownership, administration or management of:
(a) casino;
(b) keno or lottery operations;
(c) interactive gambling;
(d) race wagering or sports wagering operations (including bookmaking);
(e)
(f)
(g)
club, hotel or tavern;
the manufacture, assembling, selling, distributing, importing, supplying,
repairing or operation of gaming machine, in-line machines, lucky
envelope machines or other amusement devices;
a licensed monitoring operator.
* YES / NO
If YES, please provide details: ______________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
(iii)
Has the company, any holding company or other related body corporate been
subject to a probity investigation by any law enforcement authority or
government regulator?
* YES / NO
If YES, please provide details including name of investigating authority,
purpose of probity investigation and date of investigation:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature: ___________________________________ 22

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
(iv)
Has the company, any holding company or other related body corporate ever
provided any financial assistance or other support to any other organisation or
person involved with the ownership, administration or management of:
(a) casino;
(b) keno or lottery operations;
(c) interactive gambling;
(d) race wagering or sports wagering operations (including bookmaking);
(e)
(f)
(g)
club, hotel or tavern;
the manufacture, assembling, selling, distributing, importing, supplying,
repairing or operation of gaming machine, in-line machines, lucky
envelope machines or other amusement devices;
a licensed monitoring operator.
* YES / NO
If YES, please provide details: ______________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature: ___________________________________ 23

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
E. INFLUENCES, CONFLICT OF INTEREST AND DISQUALIFIED PERSONS
The Office of Liquor, Gaming and Racing must be advised of any matter which
could be seen as having a potential undue or improper influence on the conduct or
outcome of a probity investigation or an application for a licence. Disclosures must also
be made of persons with a potential conflict of interest or who may be classified as
disqualified persons.
(i) Are you aware of any person or shareholder associated with the company who is,
or who is the spouse or child of:
(a) a Member of the Legislative Assembly (Queensland); or
(b) a staff member of a Member of the Legislative Assembly (Queensland); or
(c) a councillor of a local government in Queensland?
* YES / NO
If YES, please supply details: ________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
(ii) Has the company, a director, employee or shareholder of the company, or any
other person or organisation acting on behalf of the company, been involved in
any lobbying, meetings, discussions or negotiations with any government official
in regard to this probity investigation or, if applicable, this or any other
application for a gaming licence?
* YES / NO
If YES, please provide details of the official’s name, name of persons acting on
behalf of the company and the date and nature of any lobbying, meetings,
discussion or negotiations held:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Signature: ___________________________________ 24

Office of Liquor, Gaming and Racing
COMPANY PROBITY FORM
CHECKLIST
Before submitting this form please complete the following checklist. If you are unable to
complete the checklist you are advised that delays in processing the application or conducting
the probity investigation may be experienced. You should advise when the outstanding
matters are to be submitted.
I hereby certify I have:
read the Instructions for Completion;
signed each page of the form;
answered all questions in writing;
answered all questions completely;
completed and signed the Certificate of Acknowledgment and Undertaking
(page 6) and Authority for Release of Information (page 7).
and attached the following:
a brief history of the company;
a Statement of Company Records;
a corporate structure flow-chart with explanatory text;
a description of the largest 20 shareholders;
a copy of the company’s Constitution or equivalent;
a copy of the Certificate of Incorporation and any Certificate of Change of Name;
copies of the financial statements for the last five (5) years;
copies of the Annual Reports for the last five (5) years; and
a copy of the Chart of Accounts.
_________________________
(Signature)
_________________________
(Name)
(End)
Signature: ___________________________________ 25

Office of Liquor, Gaming and Racing
IMPORTANT
PRIVACY STATEMENT
The Office of Liquor, Gaming and Racing (OLGR)
is collecting the information on this form so that it can
meet its responsibilities as authorised in legislation
which governs the use of this form. OLGR may need to
give some or all of this information to other
organisations or individuals as provided for in the
legislation. OLGR may publish summary information
on our website (www.olgr.qld.gov.au).
OLGR is committed to protecting your privacy and will
comply with the Queensland Treasury Privacy Plan.
If you require any clarification of this Privacy Statement
and its application for this form, please contact OLGR
for further advice.