Gaming Machine Licence Application

Gaming Machines Act 1992Gaming MachineLicence ApplicationConsumer and Business Services Use OnlyReceipt No: Amount: Initials:Date:App No:In Person at:Consumer and Business Services91 Grenfell StreetAdelaide SA 5000Part A – Applicant DetailsBy Mail at:Consumer and Business ServicesCustomer Service CentreGPO Box 2169Adelaide SA 5001By Email at:applications@agd.sa.gov.au1. Type of Applicant(s)Individual Partnership Company/Companies2. Name of Current Licensee orApplicant for the Licence(Please provide ACN ifapplicant is a company)3. Contact Details for EnquiriesRelating to this ApplicationFull NameDaytime Telephone NumberMobileFaxEmailPart B – Licensed Premises Details4.Premises Name/ProposedPremises Name5.Licence number(If an existing licence)56. Premises AddressStreet NumberStreetSuburb/townPostcodeDaytime telephone number7. Address for Service ofNotices(Where information, such as theLicence, FutureCorrespondence and AnnualLiquor Licensing Fee Invoiceswill be sent )Street/PO Box numberSuburb/townEmailPostcodeUpdated April 2015 1 of 6

Part C – Gaming Hours and Number of MachinesNote: Gaming trading hours must fall within the hours permitted under the liquor licence and can be less than thoseauthorised under the liquor licence. There must be a six hour break in each 24 hour period and there can not be acontinuous period of operation exceeding 18 hours. Gaming Machines cannot be operated for the 24 hour period ofChristmas Day or Good Friday.8. Gaming Trading HoursMonday From toTuesday From toWednesday From toThursday From toFriday From toSaturday From toSunday From toPublic holidays From toOther (please specify)9. Approval sought to possessand operate how manygaming machines?Part D – Additional Information10. PlansOne plan of the gaming room(s) (to a scale of 1:50) must accompany thisapplication, showing the layout of the gaming machines.(refer ‘Submitting a Plan - Lodgement Guide’)11. Do you hold a ResponsibleGambling Agreement with arecognised industry body? No Yes (please provide a copy)12. On Appendix A, list thepersons requiring approvalin any of the followingcategories:LicenseeDirectorCommittee MemberShareholderAdult Trust BeneficiaryPart E – Applicant’s SignatureIndemnityI hereby indemnify the Liquor and Gambling Commissioner against the costs (which will be charged at the current rateper person) of investigating each natural person being a person who is:a) The applicant or one of the applicants; orb) The person or one of the persons to whom the application relates; orc) In the case of an application made by or relating to a body corporate - a person who occupies a position ofauthority in the body corporate.Applicant’s SignatureDate / /Print NamePosition/Title

Appendix A – Persons to be ApprovedPlease photocopy if there is not enough spacePerson 11aSurnameGiven Name(s)1bDate of Birth/ / Female Male1c Category of approval Tick one or more boxes Licensee Director Shareholder Committee Member Adult Trust Beneficiary1d Previous Approval Is this person currentlyapproved ? Yes NoID No:(Note: A completed PID is required if the person hasnever been approved or had a previous approval thatceased more than 6 months ago)1eCurrent ResidentialAddressStreet NumberStreet NameSuburb / town:Postcode:1fContact DetailsPhone:Email:

Appendix A cont.– Transfer Licence ApplicationPlease photocopy if there is not enough spacePerson 22aSurnameGiven Name(s)2bDate of Birth/ / Female Male2c Category of approval Tick one or more boxes Licensee Director Shareholder Committee Member Adult Trust Beneficiary2d Previous Approval Is this person currentlyapproved ? Yes NoID No:(Note: A completed PID is required if the person hasnever been approved or had a previous approval thatceased more than 6 months ago)2eCurrent ResidentialAddressStreet NumberStreet NameSuburb / town:Postcode:2fContact DetailsPhone:Email:

Appendix A cont. – Transfer Licence ApplicationPlease photocopy if there is not enough spacePerson 33aSurnameGiven Name(s)3bDate of Birth/ / Female Male3c Category of approval Tick one or more boxes Licensee Director Shareholder Committee Member Adult Trust Beneficiary3d Previous Approval Is this person currentlyapproved ? Yes NoID No:(Note: A completed PID is required if the person hasnever been approved or had a previous approval thatceased more than 6 months ago)3eCurrent ResidentialAddressStreet NumberStreet NameSuburb / town:Postcode:3fContact DetailsPhone:Email:

Appendix A cont. – Transfer Licence ApplicationPlease photocopy if there is not enough spacePerson 44aSurnameGiven Name(s)4bDate of Birth/ / Female Male4c Category of approval Tick one or more boxes Licensee Director Shareholder Committee Member Adult Trust Beneficiary4d Previous Approval Is this person currentlyapproved ? Yes NoID No:(Note: A completed PID is required if the person hasnever been approved or had a previous approval thatceased more than 6 months ago)4eCurrent ResidentialAddressStreet NumberStreet NameSuburb / town:Postcode:4fContact DetailsPhone:Email: