APPLICATION FOR APPROVAL OF GAMING MACHINES AND PERIPHERAL EQUIPMENT If insufficient space is available for responses please attach additional information. SECTION 1 - Details of Applicant An approved Supplier may apply for approval of a gaming machine or peripheral equipment. Name of Supplier (enter text) Certificate Number (enter text) Postal address (enter text) Contact Person (enter text) Telephone (enter text) Facsimile (enter text) Email Address (enter text) Please note that an approval or refusal will be emailed to this address. SECTION 2 - Details of Gaming Machine or Peripheral Equipment Name of Gaming Machine or Peripheral Equipment (enter text) Type of Gaming Machine or Peripheral Equipment (enter text) Specification Number (enter text) Application Reference Number (enter text) Does this product allow the use of an audio device Does the product proposed to be approved introduce that is not designed or intended primarily to assist a new technology not previously approved in this person with a hearing impairment? jurisdiction? (enter text) Yes (Please attach details) Yes (Please attach details) No No GAMING REGULATION SECTION USE ONLY LICENSEE NOT TO COMPLETE THIS PART – Y N Application fee paid _____________________________ Date: ______/______/____ Signature of Delegated Officer Technical Evaluation Signature of Delegate received Approval number: NI_______________________ Research considered Application approved Date Notified:______/______/___________ AF2015-74
APPLICATION FOR APPROVAL OF GAMING MACHINES AND PERIPHERAL EQUIPMENT If insufficient space is available for responses please attach additional information. SECTION 1 - Details of Applicant An approved Supplier may apply for approval of a gaming machine or peripheral equipment. Name of Supplier (enter text) Certificate Number (enter text) Postal address (enter text) Contact Person (enter text) Telephone (enter text) Facsimile (enter text) Email Address (enter text) Please note that an approval or refusal will be emailed to this address. SECTION 2 - Details of Gaming Machine or Peripheral Equipment Name of Gaming Machine or Peripheral Equipment (enter text) Type of Gaming Machine or Peripheral Equipment (enter text) Specification Number (enter text) Application Reference Number (enter text) Does this product allow the use of an audio device that is not designed or intended primarily to assist a person with a hearing impairment? Yes (Please attach details) No Does the product proposed to be approved introduce new technology not previously approved in this jurisdiction? (enter text) Yes (Please attach details) No GAMING REGULATION SECTION USE ONLY – LICENSEE NOT TO COMPLETE THIS PART Y N _____________________________ Signature of Delegated Officer Application fee paid Date: ______/______/____ Technical Evaluation received Signature of Delegate Research considered Approval number: NI_______________________ Application approved Date Notified:______/______/___________ AF2015-74
Application-for-Approval-of-Gaming-Machines-and-Peripheral-Equipment-AF2015-74.docx