• Associate Details Form

  • PRIOR TO STARTING THIS FORM

    The following online form can be saved and returned to at a later time if required. You will be prompted to provide an email and password to re-access the incomplete form.

    You must ensure this form is complete before you submit it, as an incomplete form (including attachments) will not be accepted by the Tasmanian Liquor and Gaming Commission.

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

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

  • Associate Details

  • Associate Type:*

  • In this form, when we use the word ‘you’ we are referring to the individual or company who is to be an associate to a venue licence/authority.

    If applicable, this form can be completed on behalf of the company by a relevant Director/Manager/Secretary. However, this person will be required to agree to the stated declaration at the end of the form.

  • Date of Birth*
     - -
  • Postal Address Type
  • Contact Phone Number
  • Format: (00) 0000 0000.
  • Format: 0000 000 000.
  • Contact Person Date of Birth*
     - -

  • Association Details

  • I am an associate of an applicant or current licence holder of the following:*

  • I will be associated to the above named entity in the following manner:

  • I am a relative*
  • Are you associated with any other gaming venue/licence in Tasmania?*

  • Business Affiliations

  • Do you have any other company, or person, acting on your behalf in Australia or overseas?*
  • Do you have any other agency or branch in Australia or overseas?*
  • Have you, as the entity applying for this authority, ever changed your trading or company name?*
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  • Do you have, or do you use, or have you previously used, any other business name?*

  • Litigation History

  • Have you ever been convicted of, or pleaded guilty to, an offence?*
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  • Are you aware of any current charges or summons against you, which are before a Court for any offence or violation?*
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  • Have you had any action taken against you for not complying with a law of any jurisdiction in Australia relating to industrial relations or workplace safety?*
  • Has a director ever been disqualified from acting as such under any provision of current or previous Australian Corporations and Securities Legislation (or overseas equivalent)?*
  • Have you ever been investigated by the Australian Securities and Investments Commission or any other Government authority to your knowledge (eg RIA, APRA, ACCC)?*
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  • Do you have any amounts owing to the Australian Taxation Office?*
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  • Have you ever had any action taken against you or are you currently being investigated by the Australian Taxation Office?*
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  • Have you ever been associated with a company that is currently, or has been, investigated by the Australian Securities and Investments Commission or any other Government authority to your knowledge?*
  • Are you the subject of any civil litigation?*
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  • Gaming History

  • Do you hold a current licence/authority in the casino/gaming industry, either in Australia or overseas?*
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  • Have you applied for a licence/authority in the casino/gaming industry either in Australia or overseas?*
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  • Have you ever been the subject of disciplinary action in the context of operating in the casino/gaming industry?*
  • Have you ever been refused a licence/authority in the casino/gaming industry in Australia or overseas, or had such a licence/authority revoked?*
  • Are you, or have you previously been, an associate to another entity in the gaming industry either in Australia or overseas?*
  • Have you ever been refused approval as an associate to an entity in the gaming industry either in Australia or overseas, or had such an approval revoked?*
  • Have you ever been granted a licence/authority by Government to supply liquor, operate gaming activities, or another occupational licence required by Government?*
  • Have you ever been refused a licence/authority by Government to supply liquor, operate gaming activities, or another occupational licence/authority required by Government, or had such a licence/authority revoked?*
  • Have you ever been the subject of disciplinary action in the context of selling liquor and/or conducting gaming activities as an associate to or as the holder of a gaming licence/authority?*

  • Financial History

  • Have you ever been bankrupt or are currently an undischarged bankrupt? If yes, please provide details.*
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  • Have you ever been placed in external administration (that is liquidation, receivership, administration or scheme of arrangement)*
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  • Have you acted as guarantor for any person or entity which is currently in default of that financial agreement?*
  • 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?*
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  • Probity History

  • Have you ever been convicted of, or pleaded guilty to, an offence in Tasmania, or any other Australian state or territory? If yes, please provide details. Examples of offences may include (but are not limited to) assault, stealing, fraud, obtaining a financial advantage (traffic infringements notices are not required):*
  • Have you ever been bankrupt or are currently an undischarged bankrupt? If yes, please provide details.*
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  • Have you ever entered into a debt agreement?*
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  • Do you have any other additional relevant information you wish to share in the context of this application?*
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  • 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.

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  • Payment

  • In completing this application, you are authorising the Liquor and Gaming Branch to process this payment. No surcharge applies. Transactions will appear on bank statements as “State Revenue Office (SRO) TAS”.

    Application fees are non-refundable.

  • PAYMENT GATEWAY NOT DECIDED ON YET

  • Consent & Declaration

  • Personal Information Protection Statement

    Personal information is collected by the Department of Treasury and Finance, the Commissioner for Licensing, and the Tasmanian Liquor and Gaming Commission. The Liquor and Gaming Branch of Treasury can be contacted at Liquor and Gaming Branch, GPO Box 1374, HOBART TAS 7001; by telephone at (03) 6166 4040; or by email at gaming@treasury.tas.gov.au

    You have a right under the Personal Information Protection Act 2004 to access personal information held about you. Further information about Treasury s Personal Information Protection Policy, including how to make a request to access details of your personal information, is available at www.treasury.tas.gov.au/about-us/corporate-governance/personal-information-protection-policy

    Personal information is collected for the purposes of managing, assessing, advising on, and determining the relevant application, as well as for ongoing regulation under the Gaming Control Act 1993 (Tasmania) and relevant regulations.

    Personal information may be disclosed to contractors and agents of Treasury, as well as to courts, law enforcement agencies, finance agencies, identity verification services, and other organisations authorised to collect it.

    Failure to provide required information may mean that your application cannot be processed.

    Declaration

    I acknowledge that it is an offence under the Gaming Control Act 1993 to give false or misleading information in relation to an application for a gaming licence or permit. I also acknowledge that giving a false or misleading statement, or failing to disclose relevant information is a ground for disciplinary action. I certify that the particulars contained in the completed application form are true and correct in every detail and fully disclose the information required to complete this application.

    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)

    Consent

    I authorise and 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.

    • 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 of Treasury and Finance, the Commissioner for Licensing and/or the Tasmanian Liquor and Gaming Commission for any regulatory function or purpose under the Liquor Licensing Act 1990 or the Gaming Control Act 1993.

    • The Tasmanian Liquor and Gaming Commission, Commissioner for Licensing and any member of the Department of Treasury and Finance to obtain consumer credit information from Experian Data Registries Pty Ltd. In this context where us or we means the Liquor and Gaming Branch (Access Seeker) and you or your means the applicant or associate:

    • 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.

    • We collect information from Experian, a credit reporting body. Further information on how Experian collects, holds, uses and discloses your credit information is available from www.experian.com.au.

    • 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 submitting this form 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, {name}, the applicant, agree to the above declaration, in full, on this date {consentDate}

  • By submitting this form 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, {contactPerson208}, agree to the above declaration in full, on behalf of {companyName} on this date {consentDate}

  • Please note, this application may be refused by the Tasmanian Liquor and Gaming Commission if consent is not given.

  • Consent Date
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  • Should be Empty: