Been found guilty of an offence since attaining the age of 18? Yes No Do you have any pending offence/charge? Yes No Have your salary, wages, earnings or other income ever been subject to Yes No garnishee order, attachment or the like? Have you ever had any article repossessed by a finance company or the Yes No like? Are you an undischarged bankrupt or have you ever applied to take the benefit of any law for the relief of bankrupt or insolvent debtors Yes No compounded with creditors or made an assignment of your remuneration for their benefit? Have you ever been dismissed, discharged or asked to resign from any Yes No employment? Are you currently associated with or actively participate in the management or operations thereof as a director, partner or other Yes No capacity of any corporation, partnership, joint venture or business? Have you ever held an executive position with any company that has Yes No either been in liquidation or receivership? 5. Declaration of competency by employer (person authorised by the Licensee or if self employed declaration by owner) – I, (insert name) holding the position of (insert position) Located at (Name of business/Gaming Venue) Hereby certify that the applicant (insert full name of applicant) has the appropriate qualifications, knowledge, skills and experience to competently carry out the activities that will be authorised under the licence. If the application is successful, this person will be employed in the capacity of Gaming Machine Repairer. Signature Date 6. Supporting documents The following documents are required to be lodged with this application. Current photographic identification (copy of current drivers licence or passport) Evidence of change of name (copy if of marriage certificate or deed poll documents) applicable 2 current passport photographs Criminal History Report conducted within the last 3 months issued by SAFE NT. (New Application = Fingerprint check; Renewal application = Name check)
Been found guilty of an offence since attaining the age of 18? Yes No Do you have any pending offence/charge? Yes No Have your salary, wages, earnings or other income ever been subject to garnishee order, attachment or the like? Yes No Have you ever had any article repossessed by a finance company or the like? Yes No Are you an undischarged bankrupt or have you ever applied to take the benefit of any law for the relief of bankrupt or insolvent debtors compounded with creditors or made an assignment of your remuneration for their benefit? Yes No Have you ever been dismissed, discharged or asked to resign from any employment? Yes No Are you currently associated with or actively participate in the management or operations thereof as a director, partner or other capacity of any corporation, partnership, joint venture or business? Yes No Have you ever held an executive position with any company that has either been in liquidation or receivership? Yes No 5. Declaration of competency by employer (person authorised by the Licensee or if self employed – declaration by owner) I, (insert name) holding the position of (insert position) Located at (Name of business/Gaming Venue) Hereby certify that the applicant (insert full name of applicant) has the appropriate qualifications, knowledge, skills and experience to competently carry out the activities that will be authorised under the licence. If the application is successful, this person will be employed in the capacity of Gaming Machine Repairer. Signature Date 6. Supporting documents The following documents are required to be lodged with this application. Current photographic identification (copy of current drivers licence or passport) Evidence of change of name (copy of marriage certificate or deed poll documents) if applicable 2 current passport photographs Criminal History Report conducted within the last 3 months issued by SAFE NT. (New Application = Fingerprint check; Renewal application = Name check)