• 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

  • 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 Experian Data Registries 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 Experian, a credit reporting body. Further information on how Experian 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}

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

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  • Consent Date
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