personal information declaration form - Consumer and Business ...

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.