Form 3B - Club details for a category 2 gaming machine licence
Form 3B - Club details for a category 2 gaming machine licence
Form 3B - Club details for a category 2 gaming machine licence
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Section 12<br />
Statutory<br />
declaration<br />
Oaths Act 1867<br />
I ...........................................................................................................................................................<br />
(insert full name of principal executive officer of the club)<br />
of .........................................................................................................................................................<br />
(insert residential address of executive officer stated above)<br />
in the state of Queensland, do solemnly and sincerely declare all applicable rules, by-laws and any<br />
other incorporating documents of:<br />
............................................................................................................................................................<br />
(insert full name of club)<br />
• have been complied with in making the application <strong>for</strong> a <strong>gaming</strong> <strong>machine</strong> <strong>licence</strong> and<br />
• do not prohibit the playing of <strong>gaming</strong> <strong>machine</strong>s on the premises to which the application relates<br />
and I make this solemn declaration conscientiously believing the same to be true, and by virtue of the<br />
provisions of the Oaths Act 1867.<br />
Signature .............................................................................................................................................<br />
(signature of executive officer stated above)<br />
Taken and declared be<strong>for</strong>e me ..............................................................................................................<br />
(enter full name of Justice of the Peace or Commissioner <strong>for</strong> Declarations)<br />
at ........................................................................ this .............................................................. day of<br />
(city/suburb)<br />
(day e.g. 13th)<br />
............................................................................................................................................................ .<br />
(month)<br />
(year)<br />
Signature .............................................................................................................................................<br />
(signature of Justice of the Peace or Commissioner <strong>for</strong> Declarations)<br />
0154LG 2013<br />
OLGR is collecting your personal in<strong>for</strong>mation in order to assess your application <strong>for</strong> a <strong>gaming</strong> <strong>machine</strong> <strong>licence</strong> in accordance with s. 56 of the Gaming Machine Act 1991.<br />
OLGR may disclose your personal in<strong>for</strong>mation to the prescribed entities listed in Schedule 1 of the Gaming Machine Regulation 2002 or as otherwise required by law.<br />
Office of Liquor and Gaming Regulation Page 4 of 4
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