Personal Information Declaration - Consumer and Business Services

Personal Information Declaration (PID)Strictly ConfidentialInformation for applicantsIf you are seeking approval under the Gaming Machines Act 1992 you are required to have your fingerprints taken by SouthAustralia Police.If you have any questions about completing this Personal Information Declaration, please contact CBS by telephone on (08) 8226 8655or by email to: applications@agd.sa.gov.au. For more information visit the CBS website at www.cbs.sa.gov.au and follow the link toLiquor and Gambling information.Lodge this Personal Information Declaration with any supporting documents either—In Person at:Consumer and Business ServicesCustomer Service Centre91Grenfell StreetAdelaide SA 5000By Mail to:Consumer and Business ServicesCustomer Service CentreGPO Box 2169Adelaide SA 5001Consumer and BusinessServices Use OnlyApp Number:PID Number:Hearing Date:Police Use OnlyRECORDS SHOW No Offences Offences As Stated Not StatedINTERVENTION YES NOFor Commissioner of Police: ID: / Date: / /Part A - About The Licensed Premises (if applicable)1.Premises Licence Number:(if known)52. Name of premises orproposed name of premises:3. Name of licensee:4. Address of premises:(or proposed premises)Street number:Street name:Suburb/town:Postcode:Part B - About The Person To Be Approved5. Person to be approvedTitle:Surname:First name:Middle name/s:Gender: Male Female

Personal Information Declaration (continued)Part C - Information Required By South Australia PolicePLEASE NOTE THAT FAILURE TO DECLARE IS AN OFFENCE12. Address HistoryProvide the details of addresses that you have resided at in the last 10 years (excluding your current residential address). This MUST includeinterstate and overseas addresses, if applicable.YEAR ADDRESS COUNTRY(If Not Australia)13. Offence HistorySA POLICE will not release criminal history information over the phone. If you are unsure of your history you shouldseek a National Police Clearance Certificate from SA Police and attach it to this document.Have you ever been arrested or reported for any offence in any jurisdiction, which was proven (in any State or Territory inAustralia or another country), whether or not a conviction was recorded?STATE ORCOUNTRYDETAILS OF OFFENCEHave you ever been issued with any type of expiation notice (e.g. ‘on the spot speeding fine’) in any State or Territory inAustralia or another country?STATE ORCOUNTRYTYPE OF EXPIATION NOTICEHave you ever been charged or reported for any offence which has not yet been before court or is currently before court?DATEDETAILS OF OFFENCEHave you ever been disciplined, fined or disqualified by any tribunal, board or other authority?DATEDETAILSHave you any disciplinary proceedings pending against you?DATEDETAILSPersonal Information Declaration (February 2013) 3/6

Personal Information Declaration (continued)14. Close Associates - Respond To All SectionsProvide full details for all persons listed on this page. If you have a relative as listed below you must complete thedetails to the best of your knowledge and if the person is deceased, write “Deceased” in the address column.SURNAME GIVEN NAMES CURRENT RESIDENTIAL ADDRESSParents / Step-Parents(OR LAST KNOWN RESIDENTIAL ADDRESS)DATE OFBIRTH(ORAPPROX.AGE)Brothers & Sisters / Step-Brothers & SistersSpouse / PartnerParents / Step-Parents Of Spouse / PartnerBrothers & Sisters Of Spouse / PartnerChildren (18 Years or Older Only)15. Do any other adults, not listedabove reside with you? No Yes Provide details below including their relationship to youSURNAME GIVEN NAMES RELATIONSHIP DATE OFBIRTHPersonal Information Declaration (February 2013) 4/6

Personal Information Declaration (continued)16. Please use this area toprovide additional informationwhich did not fit on earlierpages.Please indicate the questionfor which you are providingthe additional informatione.g. Q 14.This is also an opportunity toprovide any additionalinformation in relation to theapplication for considerationby the Liquor and GamblingCommissioner or theCommissioner of Police.17. Attach two recent identicalpassport sized colourphotographs of yourself(Photographs must be no more thansix months old)The backs of both photosmust be signed by the personwitnessing this Declaration.Attach Photo HereAttach Photo HerePersonal Information Declaration (February 2013) 5/6

Personal Information Declaration (continued)Part D - Authority and Declaration (sign in the presence of the witness)I certify that the information in this Personal Information Declaration (including any attachments) is true, correct andcomplete to the best of my knowledge and belief.I certify that I have made all reasonable enquiries to obtain the information required for any details noted as ‘unknown’.I certify that I am the person shown in the photographs attached to this Personal Information Declaration.I consent to:the Liquor and Gambling Commissioner (or delegated officer) undertaking any necessary investigations orenquiries with State, Federal or International police authorities, or any other relevant agency, in determining thisapplication, including enquiries in relation to any convictions imposed on me that are spent or rehabilitated(however described) under State, Territory or Federal Legislation; andsuch information being provided to the Liquor and Gambling Commissioner (or delegated officer) by State,Federal or International police authorities, or any other relevant agency.I agree should there be any doubt as to my identity, to voluntarily submit to a set of fingerprints suitable for therequirements of fingerprint experts or analysis by South Australia Police.I authorise the Liquor and Gambling Commissioner (or delegated officer) to make any enquiries into my financial orother background and activities.I hereby, in consideration of the release of the information, release and discharge and agree to indemnify and holdharmless the State of South Australia, Consumer and Business Services, each of the Australian State/Federal/TerritoryPolice or Law Enforcement Agencies and their employees, servants and agents from and against all claims, demands,actions, suits, proceedings, costs and damages whatsoever arising out of or in any way connected with the release oruse of the information.I acknowledge that this Declaration is to be used by the Liquor and Gambling Commissioner (or delegated officer) andSouth Australia Police to determine my suitability for approval and that if it contains material which I know to be false ormisleading, I may be guilty of an offence under the Liquor Licensing Act 1997, Gaming Machines Act 1992, Casino Act1997 and/or section 140 (dishonest dealings with documents) of the Criminal Law Consolidation Act 1935.Full name of person seeking approvalSignature of person seeking approvalDate signed / /Street address of person seekingapprovalStreet numberSuburb/townStreet namePostcodeSignature of witness – licensee orauthorised representativeDate signed and witnessed / /Full name of witnessAddress of witness Street number Street nameSuburb/townPostcodeRelationship to licence holder (e.g.Licensee, Director, Legal Representative etc)Personal Information Declaration (February 2013) 6/6