personal information declaration form - Consumer and Business ...

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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.
Page 1 and 2: STRICTLY CONFIDENTIALCONSUMER AND B
Page 3 and 4: 3. CLOSE ASSOCIATES (Please respond
Page 5: 5.2 Have you any interest or involv

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