Associated Individual for Bookmaker Corporation

Applying for Approval as an Associated Individual of the holder of a Bookmaker's Registration

Before you start you must have access to
* National Police Check
   from either Victoria Police, Australian Federal Police or any other provider appearing on the most current Australian Criminal Intelligence Commission's list of Accredited 'Broker' Organisations.
* Individual Credit Report
   from either Equifax or illion
* Historical Personal Name Extract
   from the Australian Securities and Investments Commission (ASIC)

The above documents must not be more than three months old at the time of lodgement of this application.

In addition you are requested to provide a letter indicating your association with the Bookmaker. You are also required to attach a copy of both your tax return and your Notice of Assessment from the Australian Tax Office for the past three (3) financial years.

* other documentation may be required depending upon your individual circumstances.

All documentation supplied with this application must be in digital form and attached where required.

Who should complete this form?

This form is for completion by individuals seeking approval as a new associate of a current holder of a Corporate Bookmaker’s registration.

Saving your application

Your application will be auto saved during the course of your application.

A facility is available for you to save a partially completed application and return to your application for a maximum of fourteen business days. You must supply a valid email address and mobile phone number (for security validation) to use this facility.

App_TABS

Contact

I am associated with the following bookmaker's registration

	Licence number *	Licensee Name *	Associate Type *	Licensee Id	Order	Remove
	Licence number * Start typing the first part of the licence number.	Licensee Name * Start typing the first part of the entities name	Associate Type * If you do not have a direct association with the licensee, select 'No direct relationship' and complete the association fields below.	Licensee Id	Weight for row 1

I am associated with the following entities that are associated with bookmaker's registration

	Associated Entity Name	Associated Entity Key	Associated Entity Value	Associate Type	Order	Remove
	Select the following entities that are associated with licensee.	Associated Entity Key	Associated Entity Value	Associate Type Note: The Association Type 'No direct relationship' cannot appear in both Association Type fields at the same time.	Weight for row 1

1. Personal Details

Provide any other names that you have been known by	Order
	Given Names Surname	Weight for row 1

Other Legal name(s)		Order
	Title Given Names Family Name Date of name change Day Month Year	Weight for row 1

Date of Birth *

Day

Month

Year

Place of birth *

Arrival date in Australia

Day

Month

Year

Contact Number(s) *

Contact type *	Contact Number *
Contact type *	Contact Number *
Contact type *	Contact Number *
Contact type *	Contact Number *

At least one contact number is required.

Current residential address

Country

Address *

City/Suburb *

State *

Postcode *

Postal Address

Country

Address

Address 2

City/Suburb

State

Postcode

Legal

2. National Police Check information

Provide details below		Order
	Offence Date Day Month Year Nature of offence/charge Court where matter was heard Background of offence / result Attach documentation where available (optional) Maximum size: 10MB.Browse for your file, then click Upload. Allowed file types: pdf doc docx txt (png, gif, jpg, jpeg for single page documents). More information Files must be less than 10 MB. Allowed file types: pdf doc docx txt png gif jpg jpeg.	Weight for row 1

Pending Investigation/Charge details ...		Order
	Offence Date Day Month Year Nature of offence/charge Name of court Current status of investigation / charge	Weight for row 1

Enter details of each Diversion Program you ever participated in:		Order
	Program Date Day Month Year Nature of offence/charge Attach details of Diversion Program (optional) Maximum size: 10MB.Browse for your file, then click Upload. Allowed file types: pdf doc docx txt (png, gif, jpg, jpeg for single page documents). More information Files must be less than 10 MB. Allowed file types: pdf doc docx txt png gif jpg jpeg. Name of Court Background details/Explanation of the offences	Weight for row 1

3. Legal Action

Enter details for each legal action:		Order
	Nature of legal action Plaintiff Summary of the cause of the legal action and your involvement in the matter Case number and date of action Name of Court or tribunal (if applicable) Result Attach a copy of documentation confirming the court outcome or copy of the settlement agreement (if finalised) Maximum size: 10MB.Browse for your file, then click Upload. Allowed file types: pdf doc docx txt (png, gif, jpg, jpeg for single page documents). More information Files must be less than 10 MB. Allowed file types: pdf doc docx txt png gif jpg jpeg.	Weight for row 1

Regulatory

4. Directorships within Australia

List all companies placed in liquidation, receivership, administration etc.

Commencement date

Day

Month

Year

Enter other Licences/Approvals/Authorisations/Registrations:		Order
	Date of action Day Month Year Licence/Approval type Licence Number Name of Regulator Details of type of action taken and reason	Weight for row 1

Date of refusal/withdrawal

Day

Month

Year

Date of disqualification

Day

Month

Year

5. Directorships etc outside Australia

6. Employment details ...

Enter details for each licence:		Order
	You may either attach a file containing details or enter the details in the area below Maximum size: 10MB.Browse for your file, then click Upload. Allowed file types: pdf doc docx. More information Files must be less than 10 MB. Allowed file types: pdf doc docx txt png gif jpg jpeg. Licence/Approval type Name of Gambling regulator Jurisdiction "Jurisdiction" means the State or Territory and, if outside Australia, the country and locality Was the application granted/approved ? N/A No Yes You may either attach a file containing details or enter the details in the area below Maximum size: 10MB.Browse for your file, then click Upload. Allowed file types: pdf doc docx txt (png, gif, jpg, jpeg for single page documents). More information Files must be less than 10 MB. Allowed file types: pdf doc docx txt png gif jpg jpeg. Licence/Approval association dates Empty 'End date' values will use the 'Start date' values. Day Month Year to: Day Month Year Licence Number Name shown on licence, approval, etc Licence ever cancelled/suspended/revoked/amended or subject to Disciplinary Action? N/A No Yes Has this licence, approval, authorisation or registration ever been cancelled, suspended, amended, revoked or been the subject of disciplinary action by a regulatory body? Date action taken Day Month Year Attach details of cancellation etc. (optional) Maximum size: 10MB.Browse for your file, then click Upload. Allowed file types: pdf doc docx txt (png, gif, jpg, jpeg for single page documents). More information Files must be less than 10 MB. Allowed file types: pdf doc docx txt png gif jpg jpeg. Details of action taken Is Application still pending? N/A No Yes Licence ever refused or withdrawn? N/A No Yes Date of refusal/withdrawal Day Month Year Attach details of refusal / withdraw (optional) Maximum size: 10MB.Browse for your file, then click Upload. Allowed file types: pdf doc docx txt (png, gif, jpg, jpeg for single page documents). More information Files must be less than 10 MB. Allowed file types: pdf doc docx txt png gif jpg jpeg. Reason for refusal / withdrawal	Weight for row 1

Financial

7. Credit Report details

You must attach an Australian credit report if:

1) you currently live in Australia; or
2) you do not currently live in Australia but have lived in Australia at any time during the last 10 years; or
3) you are or have been during the last 10 years a director or officeholder of an Australian company

Note

If you live or have lived outside Australia for at least 12 months during the last 10 years you are required to attach an equivalent report from the relevant agency. In the event that you are unable to provide an equivalent report please attach a written explanation.

8. Debt - defaults

Debt details ...

Financial institution/creditor name	Total Amount Owing	Total Amount in default	Number of days overdue	Total Amount Owing	Total Amount in default	Remove
Financial institution/creditor name	Total Amount Owing	Total Amount in default	Number of days overdue	Total Amount Owing	Total Amount in default

9. Guarantee

10. Bankruptcy

11. Personal financial details

Attachment of tax returns and Notice of Assessment from the Australian Tax Office (ATO)

Attach a copy of both your tax returns and Notice of Assessment from the Australian Tax Office (ATO) for the last three financial years.
You can select up to 6 separate files at the prompt.
Total maximum size: 32MB. Allowed file types: pdf doc docxBrowse for your files, then click Upload.

Add a new file *

More information

Files must be less than 10 MB.
Allowed file types: pdf doc docx.

Attachments

Schedules

A. Cash at financial institutions

Please list all accounts, foreign and domestic, maintained by you solely or in conjunction with another person(s).		Order
	Name of Financial Institution * Account Name * Account Number * Account Type * Current Balance *	Weight for row 1

B. Accounts Receivable

Please list all accounts receivable held by you solely or in conjunction with another person(s). For those not solely held by you, indicate the percentage (%) you hold.		Order
	Name of debtor * Date Incurred * Day Month Year Original Amount * Unpaid Balance * % Held * Maturity Date * Day Month Year Payment Period * Interest Rate * Collateral * Purpose *	Weight for row 1

C. Shares, Fixed Interest Security (Bonds)

Please list the information requested for all shares and bonds held or controlled by you. Whenever interest exists through a trust/mutual fund or holding company, the shares held by such trust/mutual fund or holding company need not be listed. Indicate publicly traded shares and bonds.		Order
	Issuer * Types * Date of Purchase * Day Month Year No of Shares or Units * Purchase Price * Market Value * Name in which held *	Weight for row 1

D. Business investments

Please list the information requested regarding any business investment in which any direct, indirect, vested, or contingent interest is held by you, along with the names of all persons or entities that share a direct, vested or contingent interest therein. This should include but not be limited to joint ventures, partnerships, sole proprietorships and corporation. For those not solely held by you, indicate the percentage (%) you hold.		Order
	Entity * Type of Entity * Date of Purchase * Day Month Year No of Shares or Units * % Held * Purchase Price * Market Value * Name in which held * Persons or entities sharing interest & percentage of ownership *	Weight for row 1

E. Real Estate

Please list the information requested regarding any real property, vested, or contingent interest is held by you, along with the name of persons or entities who share direct, indirect, vested or contingent interest therein. For those not solely held by you, indicate the percentage (%) you hold.		Order
	Address / Location * Purchase Price / Improvement at Cost * Date of Purchase * Day Month Year Type * % Held * Other Owners * Income * Market Value *	Weight for row 1

F. Other Assets

Please list the information requested for all other assets held by you, (i.e. automobiles, personal property, cash surrender value of life insurance policies, pension plans etc.).		Order
	Date of Purchase * Day Month Year Type of Asset * Purchase Price * Market Value * Other Information *	Weight for row 1

G. Unsecured Loans

Please list the information requested for all unsecured loans payable (US notes payable) for which you are solely or partly obligated. If partly obligated, list percentage (%) of obligation.		Order
	Name of Creditor * Date Incurred * Day Month Year Original Amount * Unpaid Balance * % of Obligation * Maturity Date * Day Month Year Payment Period * Interest Rate * Purpose * Collateral *	Weight for row 1

H. Secured Loans

Please list information requested for all secured loans payable (mortgages) for which you are solely or partly obligated. If partly obligated, list percentage (%) of obligation.		Order
	Name & Address of Creditor * Date Incurred * Day Month Year Original Amount * Unpaid Balance * % of Obligation * Maturity Date * Day Month Year Payment Period * Interest Rate * Purpose * Collateral *	Weight for row 1

I. Other Liabilities

Please list information requested for any other indebtedness for which you are solely or partly obligated. If partly obligated, list percentage (%) of obligation.		Order
	Name & Address of Creditor * Date Incurred * Day Month Year Original Amount * Unpaid Balance * % of Obligation * Maturity Date * Day Month Year Payment Period * Interest Rate * Purpose * Collateral *	Weight for row 1

J. Contingent Liabilities

Please list information requested for all contingent liabilities for which you are solely or partly obligated. If partly obligated, list percentage (%) of obligation.		Order
	Name & Address of Creditor * Date Incurred * Day Month Year Original Amount * Unpaid Balance * % of Obligation * Maturity Date * Day Month Year Payment Period * Interest Rate * Purpose * Collateral * Persons other than you who are liable *	Weight for row 1

Consent and Declaration

Declaration Information

FINANCIAL INFORMATION RELEASE FORM

CONSENT FOR RELEASE OF INFORMATION OF LAW ENFORCEMENT AGENCIES

Entityform Security

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You have 14 days to retrieve and finalise your application, after which it will automatically be removed and can no longer be accessed.

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