Associate Details Form

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:*

Individual/Sole TraderCompany
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.
Company Name*
Name*

TitleFirst NameMiddle Name(s)Surname
Consolidated Name (used for notification email)
Preferred name (if different from above)
Former Names (If applicable)
Driver licence number
Driver licence state of issue
Date of Birth*

DayMonthYear
Date
Place of Birth*
Address*

Address

Address Line 2

CityState

PostcodeCountry
Postal Address

Same as above
Postal Address Type

Street AddressPostal Box
Address

Address Line 2

CityState

PostcodeCountry
Previous address(es)(if applicable within the last three years):
ABN*
ACN*
Contact Phone Number

LandlineMobile
Contact Phone Number Landline
Please enter a valid phone number.
Contact Phone Number Mobile
Please enter a valid phone number.
Email Address*
Please note: This email address will receive acknowledgement of this application as well as a summary of submitted records.
Contact Person Full Name*

TitleFirst NameMiddle NameSurname
Position at Company*
Recommended Director/Secretary or Manager
Contact Person Date of Birth*

DayMonthYear
Date
Contact Person Address*

Address

Address Line 2

CityState

PostcodeCountry

Business Affiliations
Do you have any other company, or person, acting on your behalf in Australia or overseas?*

NoYes
Please provide details*
Do you have any other agency or branch in Australia or overseas?*

NoYes
Please provide details*
Have you, as the entity applying for this authority, ever changed your trading or company name?*

NoYes
Please provide details*
Attachments (if required)

Cancelof
Do you have, or do you use, or have you previously used, any other business name?*

NoYes
Please provide details*

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 *

Cancelof
List of shareholders*

Cancelof
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

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):*

NoYes
Further Details*
Have you ever been bankrupt or are currently an undischarged bankrupt? If yes, please provide details.*

NoYes
Further Details*
Attach a copy of your bankruptcy confirmation

Cancelof
Have you ever entered into a debt agreement?*

NoYes
Further Details*
Attach a copy of your debt agreement

Cancelof
Do you have any other additional relevant information you wish to share in the context of this application?*

NoYes
Further Details*
Attachments for further details (If required)

Cancelof

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 document*

Cancelof
Additional primary document

Cancelof
Secondary document*

Cancelof
Additional secondary document

Cancelof
Any Additional Document

Cancelof

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
The Department of Treasury and Finance collects and stores your personal information on behalf of the Tasmanian Liquor and Gaming Commission (“the Commission”) and the Commissioner for Licensing (“the Commissioner”). 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 associate under the Gaming Control Act 1993 and/or your fit and proper status as an associate of a licensee or permit holder under the Liquor Licensing Act 1990. Failure to provide information may result in the person/entity that you are associated with not having their/its application considered. The Department’s Personal Information Protection Policy provides further guidance.

I authorise and consent to:

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

· the Department on behalf of the Commission and/or the Commissioner discussing the status of my associate assessment with the applicant of a relevant licence or permit;

·      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 Commissioner and/or the Commission for any regulatory function or purpose under the Liquor Licensing Act 1990 or the Gaming Control Act 1993;

·         the Department on behalf of the Commission and/or Commissioner 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 associate:

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, the person completing this form as an associate.

·         I acknowledge that the information provided by me may be used for any purpose under either the Gaming Control Act 1993 or Liquor Licensing Act 1990 as the Commission and/or Commissioner consider appropriate.

·         I understand that providing false or misleading information is an offence under the Criminal Code Act 1924 and the Gaming Control Act 1993.
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}
Consent*

I consent to be finger printed and palm printed for the Tasmanian Liquor and Gaming Commission.
Please note, this application may be refused by the Tasmanian Liquor and Gaming Commission if consent is not given.
Signature*

Clear
Reply-to email
example@example.com
Consent Date

DayMonthYear
Should be Empty:

Associate Details Form

Associate Details

Association Details

Business Affiliations

Litigation History

Gaming History

Financial History

Probity History

Proof of Identification

Payment

Consent & Declaration