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 CERTIFICATE I, ________________________________________________________________________________________ hereby declare as follows: (a) I hold the position of __________________________________________________________________ in _________________________________________________________________________________ (name of corporation) and am duly authorised to complete this form (authority to complete should be minuted). (b) I certify that the particulars contained herein are true and correct in every detail and fully disclose the information required to complete this form. SIGNED at _____________________this___________________ day of _______________________20 ____ ______________________________ (Signature) In the presence of: ______________________________ (Signature of Witness) Name of Witness: Address of Witness: _______________________________________________________________________ _______________________________________________________________________ Telephone Number of Witness: ( ___ ) _____________________ ACKNOWLEDGEMENT AND UNDERTAKING The company undertakes to supply the following information if requested to do so: (a) copies of income tax returns and tax assessments; (b) copies of minutes of shareholder and director meetings; (c) explanations relevant to the published financial statements; (d) copies of the company’s shareholder register. The company notes and acknowledges that the information requested in this Company Probity Form may not satisfy the probity requirements of the Office of Liquor, Gaming and Racing and that further information may be requested. Signature: ___________________________________ 6
Office of Liquor, Gaming and Racing COMPANY PROBITY FORM AUTHORITY FOR RELEASE OF INFORMATION BY A CORPORATION __________________________________________________________________________________ (name of corporation) of ______________________________________________________________________________ (address) hereinafter referred to as “the Corporation”: 1. acknowledges that the Casino Control Act 1982, the Gaming Machine Act 1991, the Keno Act 1996, the Lotteries Act 1997, the Interactive Gambling (Player Protection) Act 1998 Racing Act 2002 and/or the Wagering Act 1998 (“the Acts”) authorises the Treasurer and/or Under Treasurer of the State of Queensland (a State of Australia) to cause to be made investigations about the Corporation for the purposes of determining the Corporation’s suitability for the purposes of the Acts; 2. authorises the Treasurer, Under Treasurer and any person conducting any investigations or enquires on behalf of the Treasurer or Under Treasurer for the purposes of the Acts, including any officer of the Office of Liquor Gaming and Racing (“Authorised Person”), to obtain any information and make any investigations or enquiries which relate to the Corporation and may be relevant to any of the purposes of the Act, in any jurisdiction; 3. authorises an officer of the Australian Taxation Office, the manager or other principal officer of any branch or office of a bank or financial institution in any jurisdiction to whom a copy of this authority is presented to allow any Authorised Person to inspect and obtain copies of, or to release to any Authorised Person, any record, document or other information of any kind in written, electronic or any other form, which relates to the Corporation and is held by the Australian Taxation Office, bank or financial institution; and 4. authorises any officer of any police service, law enforcement agency or regulatory body in any jurisdiction to whom a copy of this authority is presented to release to any Authorised Person any information or official record of any kind in written, electronic or any other form, which relates to the Corporation and is held by the police service, agency or body, including any information relating to the criminal history of the Corporation. The Corporation undertakes that it will at all times sufficiently indemnify those officers referred to in “3” and “4” above and the Authorised Person and keep those officers referred to in “3” and “4” above and the Authorised Person indemnified against all liability in respect of the supply or disclosure in accordance with the Acts, of the information, and against all actions, suits, proceedings, claims, demands, costs and expenses whatsoever which may be taken against those officers referred to in “3” and “4” above and the Authorised Person or incurred or become payable by those officers referred to in “3” and “4” above or the Authorised Person in respect thereof. SIGNED under the Common Seal this ________________ day of _____________________ 20 _____ Seal affixed by: _____________________________ (Signature of authorised person) _____________________________ (Name and position) _____________________________ (Signature of authorised person) _____________________________ (Name and position) Signature: ___________________________________ 7
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Office of Liquor, Gaming and Racing<br />
COMPANY PROBITY FORM<br />
CERTIFICATE<br />
I, ________________________________________________________________________________________<br />
here<strong>by</strong> declare as follows:<br />
(a)<br />
I hold the position of __________________________________________________________________<br />
in _________________________________________________________________________________<br />
(name of corporation)<br />
and am duly authorised to complete this <strong>for</strong>m (authority to complete should be minuted).<br />
(b)<br />
I certify that the particulars contained herein are true and correct in every detail and fully disclose the<br />
in<strong>for</strong>mation required to complete this <strong>for</strong>m.<br />
SIGNED at _____________________this___________________ day of _______________________20 ____<br />
______________________________<br />
(Signature)<br />
In the presence of:<br />
______________________________<br />
(Signature of Witness)<br />
Name of Witness:<br />
Address of Witness:<br />
_______________________________________________________________________<br />
_______________________________________________________________________<br />
Telephone Number of Witness: ( ___ ) _____________________<br />
ACKNOWLEDGEMENT AND UNDERTAKING<br />
The company undertakes to supply the following in<strong>for</strong>mation if requested to do so:<br />
(a) copies of income tax returns and tax assessments;<br />
(b) copies of minutes of shareholder and director meetings;<br />
(c) explanations relevant to the published financial statements;<br />
(d) copies of the company’s shareholder register.<br />
The company notes and acknowledges that the in<strong>for</strong>mation requested in this Company Probity <strong>Form</strong> may not<br />
satisfy the probity requirements of the Office of Liquor, Gaming and Racing and that further in<strong>for</strong>mation<br />
may be requested.<br />
Signature: ___________________________________ 6
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