Roll Listing Application

Roll Listing Application - Prior To Starting Application
In this application, when we use the word ‘you’ we are referring to the entity applying for listing on the Roll of Recognized Manufacturers, Suppliers and Testers of Gaming Equipment.

The following online application form can be saved and returned to at a later time if required.

Applicants must ensure their application is completed, as incomplete applications (including attachments) will not be accepted by the Tasmanian Liquor and Gaming Commission.

Please note it is an offence to provide false and misleading information at any stage during this process.

Electronic documents or photos lodged must be in .pdf, .doc, .docx, .xls, .xlsx, .zip, .mpg, .jpg, .jpeg, .png or .gif file formats.

Applicant Type
Please tick one or more of the following options relating to activities you are undertaking:
Manufacturer of gaming equipment
Please describe what service(s) you intend to offer.*
Supplier of gaming equipment
Please describe what service(s) you intend to offer.*
Supplier of testing services
Please describe what service(s) you intend to offer.*
Possess gaming equipment
Please describe what service(s) you intend to offer.*
Sell gaming equipment
Please describe what service(s) you intend to offer.*
Provide ancillary gaming services
Please describe what service(s) you intend to offer.*

Applicant Details
Entity Type

CompanyPartnershipIndividual/Sole Trader
{entityType} Applicant Details
Company name*
Entity/club name*
Partnership name*
Individual name*

TitleGiven NameMiddle Name(s)Surname
Preferred name (if different to above)
Previous Name(s) (if applicable)
Date of birth*

DayMonthYear
Date
Email address*
example@example.com
Trading name*
Linked to a trust for the purposes of this application?*

NoYes
Full name of linked entity/trust*
Registered Address Type

Street AddressPostal Box
Registered Address*

Address

Address Line 2

CityState

PostcodeCountry
PO Box Address*

Address

Address Line 2

CityState

PostcodeCountry
Previous Address(es) (if applicable within the last three years)
ABN*
ACN*
Incorporation Number*
Business Contact Number
Business Contact Landline*
Please enter a valid phone number.
Business Contact Mobile*
Please enter a valid phone number.
Enter names of all partners (IMPORTANT - All partners MUST lodge an Associate Details Form with this application)*
Attachments
Certificate of Registration of a Company with ASIC*

Cancelof
Certificate of Incorporation & copies of incorporating documents*

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Trust Deed*

Cancelof
Certificate of Registration for the business name*

Cancelof
Current lease (must be in the full name of the applicant) *

Cancelof
Partnership agreement*

Cancelof
Constitution*

Cancelof

Gaming History
Do you hold a current authority in the casino/gaming industry, either in Australia or overseas?*

NoYes
Documentation of authority type, state/territory/country and name of relevant regulator*

Cancelof
Have you applied for an authority in the casino/gaming industry either in Australia or overseas?*

NoYes
Documentation of authority type, state/territory/country and name of the relevant regulator*

Cancelof
Have you ever been refused an authority in the casino/gaming industry in Australia or overseas, or had such an authority revoked?*

NoYes
Have you ever been the subject of disciplinary action in the context of operating in the casino/gaming industry?*

NoYes
Please provide further details

Proof of Identification
To establish the identity of a person, evidence of identity is required. The list of accepted identity documents is available at Proof of identity | Treasury and Finance Tasmania

Electronic documents or photos lodged must be in .pdf, .doc, .docx, .zip, .mpg, .jpg, .jpeg, .png or .gif file formats.
Primary identification document*

Cancelof
Additional primary identification document

Cancelof
Secondary identification document*

Cancelof
Additional secondary identification document

Cancelof
Any additional document

Cancelof
Have you ever been bankrupt, or are currently an undischarged bankrupt?*

NoYes
Have you ever entered into a debt agreement?*

NoYes
Confirmation of authorisation

I confirm that I am authorised to provide the personal details presented and I consent to my information being checked with the document issuer or official record holder via third party systems for the purpose of confirming my identity.

Financial History
Have you ever been bankrupt or are currently an undischarged bankrupt? If yes, please provide details.*

NoYes
Bankruptcy details*
Relevant bankruptcy documentation*

Cancelof
Have you ever been placed in external administration (that is liquidation, receivership, administration or scheme of arrangement)*

NoYes
Further details*
Attach details if applicable*

Cancelof
Have you acted as guarantor for any person or entity which is currently in default of that financial agreement?*

NoYes
Please provide further details*
Do you have any financial interest whether directly or indirectly, with an individual or in any business, whether registered or not, in Australia or elsewhere?*

NoYes
Please provide further details*
Details of company corporate structure*

Cancelof
Details of all holding, subsidiary and related companies, including details of business conduct by such companies *

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List of shareholders*

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Financial statements of your business consisting of a balance sheet, profit and loss statement and explanatory notes for the past three (3) years*

Cancelof
A copy of the most recent auditor’s report on the financial affairs of your business*

Cancelof

Nominated Associate Details
Contact person details (The nominated associate is the person who will be the ongoing contact for this application and authority. This person MUST be an associate of the applicant.)*

TitleGiven NameMiddle Name(s)Surname
Nominated Associate Email Address*
Please note: This email address will receive acknowledgement of this application as well as a summary of submitted records.
Preferred name (if different from above)
Work phone number*
Please enter a valid phone number.
Mobile phone number*
Please enter a valid phone number.
I confirm I have attached an Associate Details Form to this application

Payment
Your application fee is $955.

You will need to pay this application fee before you submit your form. Please make an Electronic Funds Transfer for the total application fee amount to the following bank account:

BSB: 037-001

Acc No. 268825

Acc Name: Revenue EFT

Reference/Description: RL "Your applicant name"

Please note: Applicant name that you include in the EFT reference/description may not contain hyphens, apostrophes or special characters. Please limit Reference to 18 characters.

Please include the Receipt number generated for your EFT transaction below.
EFT Transaction Receipt Number*
Please enter receipt number from EFT Transfer
EFT Transaction Receipt*

Cancelof

Consent & Declaration
The Department of Treasury and Finance collects and stores your personal information on behalf of the Tasmanian Liquor and Gaming Commission (“the Commission”). You have the right to access information collected about you under the Personal Information Protection Act 2004. This information will be considered as part of your ongoing suitability as an applicant/prescribed licence holder under the Gaming Control Act 1993. Failure to provide all required information may result in the application not being considered. The Department’s Personal Information Protection Policy provides further guidance.

I authorise and consent to:

·         the Department on behalf of the Commission obtaining information about me from any person, entity, body or government agency;

·         the Department on behalf of the Commission, disclosing information to any contact person nominated by me at any time;

·         a copy of this consent and my personal information being provided to Tasmania Police or any Australian law enforcement agency for the purpose of conducting a Nationally Coordinated Criminal History Check. I also consent to the release of any criminal history records recorded against my name in any Australian jurisdiction to the Department on behalf of the Commission for any regulatory function or purpose under the Gaming Control Act 1993.

·         the Commission and any member of the Department to obtaining consumer credit information from illion (DBCC Pty. Ltd). In this context, “us” or “we” means the Department (Access Seeker) and “you” or “your” means the applicant:

a) By nominating us as an Access Seeker, we will be using your access rights to consumer credit information which means that you may be charged in the future for information that would have been available for free from credit reporting bodies.

b)   We collect information from illion, a credit reporting body. Further information on how illion collects, holds, uses and discloses your credit information is available from www.checkyourcredit.com.au.

c)   To make a change to credit information, you need to say how it is wrong and provide documentation to support your view. You agree to provide the credit reporting body (through us) certified copies of documents or statutory declarations where no other documentation is available (“Supporting Documentation”). Where we represent you in any required correction of information, you agree that we will provide the Supporting Documentation to the credit reporting body, and we will be responsible for providing the credit reporting body’s response to your correction request to you both truthfully and accurately.

By completing this form:

·         I confirm that I am authorised to provide the personal details presented and I consent to my information being checked with the document issuer or official record holder via third party systems for the purpose of confirming my identity.

·         I acknowledge the above and declare that the information I have provided is correct and relates to me.

·         I understand that the provision of false or misleading information is a serious offence under the Criminal Code Act 1924 and the Gaming Control Act 1993.
Name of Signatory*

First NameLast Name
By submitting this application and providing my email address, I consent to information being given by means of electronic communication as defined by the Electronic Transactions Act 2000 (Tasmania).

I, {nameOf} the applicant, agree to the above declaration.
By submitting this application and providing my email address, I consent to information being given by means of electronic communication as defined by the Electronic Transactions Act 2000 (Tasmania).

I, {contactPerson}, agree to the above declaration in full, on behalf of {companyName109}.
Signature*

Clear

If all details are correct, please click submit.
Should be Empty:

Roll Listing Application - Prior To Starting Application

Applicant Type

Applicant Details

{entityType} Applicant Details

Attachments

Business Affiliations

Litigation History

Gaming History

Proof of Identification

Financial History

Associate Details

Nominated Associate Details

Payment

Consent & Declaration