instant credit card applications

Application for an Instant Lottery Ticket Supplier’s Licence Lottery and Gaming Regulations 2008 Lottery Licensing (ABN 15 088 976 178) Level 3, East Wing 50 Grenfell St Adelaide SA 5000 GPO Box 672 Adelaide SA 5001 t 08 8226 8500 f 08 8226 8588 e lottery@agd.sa.gov.au w olgc.sa.gov.au Office use only Date Received Application No Granted By ____________________ ____________________ _____________________ Fee Paid Licence No Assessor ____________________ P ______________________________ __________________ Receipt No ____________________ Expiry Date____________________ This application must be accompanied by a fee of: • $1,374.00 new applications • $ 135.00 renewal of licence Please complete all sections: Section 1 PRINT IN BLOCK LETTERS ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ___________________________________________________ Postcode _________________________ Name of applicant Name of business Address of business Nature of applicant’s principal business Postal address ABN Telephone numbers _________________________________________________ Work Fax _____________________________ _____________________________ Home Mobile __________________________________ __________________________________ Email _______________________________________________________ Licence to be sent via (tick ( ) one only) Post Email Fax Name and address of each partner, director, manager or other person controlling the management of the business supplying the tickets under the licence. ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Application for an Instant Lottery Ticket Supplier’s Licence Lottery and Gaming Regulations 2008 Review date: August 2008 _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 1ı3 Application for an Instant Lottery Ticket Supplier’s Licence Lottery and Gaming Regulations 2008 Section 2 Within the last ten years, has the applicant Yes No Been licensed or registered in any other Australian State or Territory to supply instant lottery tickets? If yes, give details: ________________________________________________________________________________________ _____________________________________________________________________________________________________________ Been refused the right or restricted in the right to carry on a trade, business or profession for which some form of registration, licence or other authority is required by law (whether in this State or another Australian State or Territory)? If yes, give details: Yes No ________________________________________________________________________________________ _____________________________________________________________________________________________________________ Been convicted (in this State or jurisdiction) of an offence other than traffic or parking offences? If yes, give details: Yes No ________________________________________________________________________________________ _____________________________________________________________________________________________________________ Carried on business (in this State or jurisdiction) under any name other than the name or names shown on this application? If yes, give details: Yes No ________________________________________________________________________________________ _____________________________________________________________________________________________________________ Had judgement given against the applicant (in this State or jurisdiction) in civil proceedings in which fraud, misrepresentation or dishonesty was an element? If yes, give details: Yes No ________________________________________________________________________________________ _____________________________________________________________________________________________________________ Been wound up, placed in receivership, declared bankrupt, compounded with creditors or been the subject of similar proceedings (in this State or jurisdiction) arising out of an inability to pay debts? If yes, give details: Yes No ________________________________________________________________________________________ _____________________________________________________________________________________________________________ Had any experience in the supply of instant lottery tickets? If yes, give details: Yes No ________________________________________________________________________________________ _____________________________________________________________________________________________________________ Application for an Instant Lottery Ticket Supplier’s Licence Lottery and Gaming Regulations 2008 Review date: August 2008 2ı3 Application for an Instant Lottery Ticket Supplier’s Licence Lottery and Gaming Regulations 2008 Section 3 Details of classes of instant lottery tickets to be supplied pursuant to the licence: (samples of each must be provided) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Note: Please ensure this application is accompanied with• A letter from the applicant’s ADI* manager certifying as to the applicant’s banking record and history with the ADI *Authorised Deposit-taking Institution Declaration PRINT IN BLOCK LETTERS I declare that I am authorised to make this application and the contents of and the information provided with this application are true and correct. I am aware that it is an offence against the Lottery and Gaming Act 1936 for a person involved (as principal, agent or employee) in the conduct of the lottery to act in a dishonest, deceptive or misleading manner in connection with the lottery. Name of applicant Address _____________________________________________________ ____________________________________________________________________________________ _______________________________________________ Postcode _________________________ Office held by applicant Signature: _________________________________________________________ ___________________________________________________ Date: __________________ Application for an Instant Lottery Ticket Supplier’s Licence Lottery and Gaming Regulations 2008 Review date: August 2008 3ı3 Credit Card Application/Payment Option Details Lottery and Gaming Regulations 2008 Lottery Licence Lottery Licensing (ABN 15 088 976 178) Level 3, East Wing 50 Grenfell St Adelaide SA 5000 GPO Box 672 Adelaide SA 5001 t 08 8226 8500 f 08 8226 8588 e lottery@agd.sa.gov.au w olgc.sa.gov.au Payment can be made by • • • Cash or Eftpos transaction (in person) Credit card (see below) Cheque or money order (made payable to Office of the Liquor and Gambling Commissioner) Paying in person Payment can be made in person at: Office of the Liquor and Gambling Commissioner Level 9, East Wing 50 Grenfell Street Adelaide SA 5000 Paying by post Payment can be forwarded to: Lottery Licensing Office of the Liquor and Gambling Commissioner GPO Box 672 Adelaide SA 5001 For further information Visit our website: Telephone: www.olgc.sa.gov.au (08) 8226 8500 Checklist for payments Have you completed all of the requirements of the form you are lodging? Has the form been signed by the applicant? Has the authorisation for payment by credit card been completed and signed? ------------------------------------------------------------------------------------------------------------------------------Authorisation for payment by credit card Visa card Mastercard Diners card Amex card Credit Card number _____________/_________________ / ________________ / _________________ Expiry date _________________ / ________________ Amount to be withdrawn from credit card Name on card Contact phone number(s) Cardholder’s signature $ _________________________________________________________________________ _______________________________________________________________________________________________________________________________ _________________________________________________ ___________________________________________________________________ _______________________________________________________________________________________________________________________________ Payment facilities Lottery and Gaming Regulations 2008 Review date: August 2008 1ı1