personal information declaration form - Consumer and Business ...

STRICTLY CONFIDENTIALCONSUMER AND BUSINESS SERVICESChesser House, 91 Grenfell Street, Adelaide, South Australia, 5000.Postal Address: GPO Box 2169, Adelaide, South Australia, 5001.Telephone: (08) 8226 8493Fax (08) 8204 9697PERSONAL INFORMATION DECLARATIONIN SUPPORT OF AN APPLICATION FOR:Please indicate category sought ( )APPLICATION NO:()AUTHORISED BETTING OPERATIONS ACT 2000Tick one box in this section()Bookmaker LicenceAgent LicenceFAMILY NAME:GIVEN NAMES:This form must be completed in CLEAR, LEGIBLE WRITING. If there is insufficient space please attach aseparate sheet.PLEASE SIGN AND DATE THE FOOT OF EACH PAGE and extra sheet.Police use Only - Records Show: NO OFFENCES / OFFENCES - AS STATED- NOT STATEDREPORT YES / NOPID NOfor COMMISSIONER OF POLICE.................................. Date: / / I.D.........../.......1Please print and remember to have your fingerprints taken if you are seeking to be approved under theAuthorised Betting Operations Act 2000 by phoning 08 7322 3342 within 14 days of lodging this form.

1. PERSONAL INFORMATION1.1FamilyNameGivenNamesPresent residentialaddressTelephone number (Home)Fax number(Work)PostcodeSex: Male / Female Date of Birth / / Any other names (including birth, maiden, married, changed legally or otherwise and alias names) bywhich you have been known:Place of birth:Country of birth:Australian Citizen by naturalisationIf by naturalisation, provide certificate number:If a non-Australian citizen, passport/identity number:Country of issue:2. ADDRESS HISTORYExcluding your present address and working backwards, complete the following details for each addressat which you have resided in the last ten years.YEARADDRESSPlease enclose (2) two passport size photographs.Signature.....................................................................................Date...../...../.....2Please print and remember to have your fingerprints taken if you are seeking to be approved under theAuthorised Betting Operations Act 2000 by phoning 08 7322 3342 within 14 days of lodging this form.

3. CLOSE ASSOCIATES (Please respond to all sections on this page or if they do not apply to youmark them “N/A” if unsure please contact 8226 8600)FAMILY NAME GIVEN NAMES RESIDENTIAL ADDRESS DATE OF BIRTH(e.g.) SMITH JOHN 123 BROWN STREET ADELAIDE 5000 01/01/1970PARENTS______________ _____________ _______________________ / /______________ _____________ _______________________ / /BROTHERS & SISTERS______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /SPOUSE/ PARTNER______________ _____________ _______________________ / /CHILDREN 18 YEARS or OLDER ONLY______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /OTHER MEMBERS OF YOUR HOUSEHOLD – persons not listed above but living at your residentialaddress______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /PARTNERS/JOINT VENTURERS – in relation to any business______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /______________ _____________ _______________________ / /Signature.....................................................................................Date...../...../.....3Please print and remember to have your fingerprints taken if you are seeking to be approved under theAuthorised Betting Operations Act 2000 by phoning 08 7322 3342 within 14 days of lodging this form.

4. EMPLOYMENT HISTORYIncluding your present occupation and working backwards, complete the following details for each periodof employment in the last ten years..PERIODDETAILS5. LICENCE DETAILSHave you held, or do you currently hold, a licence/certificate, or have approval as a person in a position ofauthority, responsible person, or employee, under liquor/gaming/casino/wagering legislation in this State orelsewhere?YES/NO - If Yes, please complete belowType of ApprovalState orTerritoryID NumberDateGrantedDateExpired5.1 Have you ever been refused or withdrawn an application for any of the categories listed above in this Stateor elsewhere?YES/NO - If Yes, please complete belowApplication TypeState orTerritoryDate ofApplicationReason for RefusalSignature.....................................................................................Date...../...../.....4Please print, and remember to have your fingerprints taken if you are seeking to be approved under theAuthorised Betting Operations Act 2000 by phoning 08 7322 3342 within 14 days of lodging this form.

5.2 Have you any interest or involvement in any other licence or premises licensed under liquor licensing,casino or gaming machine legislation in this State or elsewhere?YES/NOIf YES, give particulars6. CREDIT WORTHINESSHave you ever been declared bankrupt, entered into a formal scheme of arrangement with your creditorsincluding a (part 10 agreement) or had judgement entered against you for debt in any court?YES/NOIf YES, give particulars including place and date. If discharged as a bankrupt, give date ofdischarge and place.6.1 Have you or any body corporate of which you have been a director or shareholder, any outstanding debtsincurred in the course of conducting any previous enterprises?YES/NOIf YES, give particularsSignature.................................................................................Date...../...../.....5Please print, and remember to have your fingerprints taken if you are seeking to be approved under theAuthorised Betting Operations Act 2000 by phoning 08 7322 3342 within 14 days of lodging this form.

7. RELEVANT WAGERING EXPERIENCEDo you have any experience in these areasIf YES please detail your experience below.Bookmaker(e.g. Your experience in acting as a bookmaker)YES/NOBookmaker Agent(e.g. Your experience in acting a bookmaker’s agent or clerk)YES/NOOther knowledge or experience relevantto Wagering Industry(e.g. Your experience as a punter, racing industry official, etc)YES/NOSignature....................................................................................Date ...../...../.....6Please print, and remember to have your fingerprints taken if you are seeking to be approved under theAuthorised Betting Operations Act 2000 by phoning 08 7322 3342 within 14 days of lodging this form.

*** FAILURE TO DECLARE IS AN OFFENCE ***IT IS YOUR RESPONSIBILITY TO ENSURE ACCURACY. IF YOU ARE IN ANY DOUBTWHATSOEVER CONTACT THE POLICE LICENSING & ENFORCEMENT BRANCH ON:(08) 7322 3342.8. OFFENCE HISTORY - you must answer each and every question either YES or NOHave you EVER been charged with or reported for ANY offence in ANY jurisdiction which was found proven in this State,other State/ Territory or Country, whether or not a conviction was recorded? - (including but not limited to, Criminal,Summary, Traffic, Firearms, Military, Liquor, Gaming, Wagering and Casino offences - Not Minor Offences dealt withunder Part 2 of the Young Offenders Act 1993.)YES/NO - If YES please state the offence, the court and date and the name under which you appeared in courtand the result. (attach additional list if required)(e.g. DRINK DRIVING 1/1/90 AT ADELAIDE MAGISTRATE’S COURTOFFENSIVE LANGUAGE 6/6/85 AT ADELAIDE MAGISTRATE’S COURT8.1 Have you been charged or reported for any offence which has not yet been before court, or is currentlybefore the court?YES/NO - If YES please state the offence and date on which it occurred.8.2 Have you been disciplined, fined or disqualified by any Tribunal, Board or other Authority ?(eg Business Licensing) in this State, other State or Territory or CountryYES/NO - If YES please state the offence and date on which it occurred.8.3 Is there any disciplinary proceedings against you pending?YES/NO - If YES please provide details.Signature............................................................................................Date ...../...../.....7Please print, and remember to have your fingerprints taken if you are seeking to be approved under theAuthorised Betting Operations Act 2000 by phoning 08 7322 3342 within 14 days of lodging this form.

9. AUTHORITY TO RELEASE CRIMINAL HISTORY INFORMATIONI,ofconsent to South Australian Police being provided a list of my named close associates, as defined underthe Authorised Betting Opertions Act 2000, and releasing to the Liquor and Gambling Commissioner mycriminal history record (if any) and any information relevant to the assessment of my suitability to hold alicence under section 34 of the Authorised Betting Operations Act 2000 at the time of my application for alicence and on an ongoing basis.I indemnify the Liquor and Gaming Commissioner and the Commissioner of Police against all actions thatmay be made in regard to the release of any particulars or information.Signature...............................................................................Date ...../...../.....WITNESSWitnessed by (Signature):Full name:Current residential address:Phone:PENALTY FOR SUPPLYING ANY FALSE OR MISLEADINGINFORMATION:-- AUTHORISED BETTING OPERATIONS ACT 2000:A person must not make a statement that is false or misleading ina material particular (whether by reason of the inclusion oromission of any particular) in any information furnished, or recordkept, under this Act – Maximum Penalty $20,000.8Please print, and remember to have your fingerprints taken if you are seeking to be approved under theAuthorised Betting Operations Act 2000 by phoning 08 7322 3342 within 14 days of lodging this form.