Form 2 Application for Eligibility Certificate by a Corporation (PDF ...

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Office of Liquor, Gaming and Racing COMPANY PROBITY FORM INSTRUCTIONS FOR COMPLETION 1. The Company Probity Form must be completed by: • the Principal Executive Officer; or • if the Principal Executive Officer does not have knowledge of the relevant facts, another person who has the knowledge and is authorised by the company to complete this form and which authority has been minuted. 2. Type or print in BLOCK LETTERS an answer to every question. 3. If an electronic version of this form is being completed, information supplied in response to a question may be inserted but no question, or the order of questions, is to be altered. 4. If a question does not apply to the company state “N/A” in response to that question. 5. If there is nothing to disclose in reply to a particular question state “Nil” in response to that question. 6. If there is insufficient space on a printed form in which to answer a question, additional information may be provided on an attachment page. When required to use an attachment page precede each answer thereon with the title applicable to that question and PRINT the company name on the page. 7. All dates should be completed in the form: Day / Month / Year. 8. Each page of this form and each attached page should be signed by the person completing the form in the space provided. 9. This form is to be completed in the English language. Any documents required to be provided are to have a certified English translation appended. 10. Documents or other information sought from authorities in Australia may not be applicable to a company which has been incorporated in another country or which originates from a company located overseas. In such cases the documents or equivalent information should be obtained from the relevant authority of that country. 11. An asterisk (*) signifies “Delete whichever is not applicable”. Signature: ___________________________________ 4
Office of Liquor, Gaming and Racing COMPANY PROBITY FORM 12. The completed form should be forwarded to: The Executive Director Office of Liquor, Gaming and Racing Locked Bag 180 CITY EAST QLD 4002 AUSTRALIA 13. This form should be sealed in an envelope and marked: “Private and Confidential Attention: Executive Director, Office of Liquor, Gaming and Racing”. 14. Any further inquiries should be directed to the Probity Section, Office of Liquor, Gaming and Racing, telephone (07) 3872 0852. (For calls outside Australia, the number is 61 7 3872 0852.) 15. Note: A reference to a corporation includes a person. 16. Persons completing this form may require to be interviewed by officers of the Office of Liquor, Gaming and Racing on one or more occasions. If you are required to be interviewed the place and form of the interview will be at the discretion of the Office of Liquor, Gaming and Racing. All persons to be interviewed are required to bear their own cost of travel and accommodation, if applicable. 17. Persons completing this form should be aware that probity investigations will not be commenced until required information is provided. In addition, a probity investigation may be halted where additional information sought is not provided in a timely manner. Acts administered by the Office of Liquor, Gaming and Racing also allow for penalties to be imposed for the failure to supply information. Signature: ___________________________________ 5
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Form 2 Application for Eligibility Certificate by a Corporation (PDF ...

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