Form 2 Application for Eligibility Certificate by a Corporation (PDF ...
Form 2 Application for Eligibility Certificate by a Corporation (PDF ... Form 2 Application for Eligibility Certificate by a Corporation (PDF ...
Office of Liquor, Gaming and Racing COMPANY PROBITY FORM E. INFLUENCES, CONFLICT OF INTEREST AND DISQUALIFIED PERSONS The Office of Liquor, Gaming and Racing must be advised of any matter which could be seen as having a potential undue or improper influence on the conduct or outcome of a probity investigation or an application for a licence. Disclosures must also be made of persons with a potential conflict of interest or who may be classified as disqualified persons. (i) Are you aware of any person or shareholder associated with the company who is, or who is the spouse or child of: (a) a Member of the Legislative Assembly (Queensland); or (b) a staff member of a Member of the Legislative Assembly (Queensland); or (c) a councillor of a local government in Queensland? * YES / NO If YES, please supply details: ________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ (ii) Has the company, a director, employee or shareholder of the company, or any other person or organisation acting on behalf of the company, been involved in any lobbying, meetings, discussions or negotiations with any government official in regard to this probity investigation or, if applicable, this or any other application for a gaming licence? * YES / NO If YES, please provide details of the official’s name, name of persons acting on behalf of the company and the date and nature of any lobbying, meetings, discussion or negotiations held: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Signature: ___________________________________ 24
Office of Liquor, Gaming and Racing COMPANY PROBITY FORM CHECKLIST Before submitting this form please complete the following checklist. If you are unable to complete the checklist you are advised that delays in processing the application or conducting the probity investigation may be experienced. You should advise when the outstanding matters are to be submitted. I hereby certify I have: read the Instructions for Completion; signed each page of the form; answered all questions in writing; answered all questions completely; completed and signed the Certificate of Acknowledgment and Undertaking (page 6) and Authority for Release of Information (page 7). and attached the following: a brief history of the company; a Statement of Company Records; a corporate structure flow-chart with explanatory text; a description of the largest 20 shareholders; a copy of the company’s Constitution or equivalent; a copy of the Certificate of Incorporation and any Certificate of Change of Name; copies of the financial statements for the last five (5) years; copies of the Annual Reports for the last five (5) years; and a copy of the Chart of Accounts. _________________________ (Signature) _________________________ (Name) (End) Signature: ___________________________________ 25
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Office of Liquor, Gaming and Racing<br />
COMPANY PROBITY FORM<br />
CHECKLIST<br />
Be<strong>for</strong>e submitting this <strong>for</strong>m please complete the following checklist. If you are unable to<br />
complete the checklist you are advised that delays in processing the application or conducting<br />
the probity investigation may be experienced. You should advise when the outstanding<br />
matters are to be submitted.<br />
I here<strong>by</strong> certify I have:<br />
<br />
<br />
<br />
<br />
<br />
read the Instructions <strong>for</strong> Completion;<br />
signed each page of the <strong>for</strong>m;<br />
answered all questions in writing;<br />
answered all questions completely;<br />
completed and signed the <strong>Certificate</strong> of Acknowledgment and Undertaking<br />
(page 6) and Authority <strong>for</strong> Release of In<strong>for</strong>mation (page 7).<br />
and attached the following:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
a brief history of the company;<br />
a Statement of Company Records;<br />
a corporate structure flow-chart with explanatory text;<br />
a description of the largest 20 shareholders;<br />
a copy of the company’s Constitution or equivalent;<br />
a copy of the <strong>Certificate</strong> of Incorporation and any <strong>Certificate</strong> of Change of Name;<br />
copies of the financial statements <strong>for</strong> the last five (5) years;<br />
copies of the Annual Reports <strong>for</strong> the last five (5) years; and<br />
a copy of the Chart of Accounts.<br />
_________________________<br />
(Signature)<br />
_________________________<br />
(Name)<br />
(End)<br />
Signature: ___________________________________ 25
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