Personal Information Declaration - Consumer and Business Services

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