Internet Gaming Key Employee
Licence
Department of
Business
Page
1 of 4
Gaming Control (Internet Gaming) Regulations
Please print in block letters. If there is insufficient space, attach extra sheets. All questions
must be answered and full particulars provided.
Internet Gaming Key Employee Licence
1. Licence details
Application for Internet Gaming Key Employee Licence (new)
Application for Internet Gaming Key Employee Licence (renewal)
Licence Number
2. Applicant details
Title
Mr Mrs Ms Miss
Full Name
Date of Birth
Place of birth
Current Residential
address
Current Postal address
Telephone
Mobile
Facsimile
Email
Are you an Australian citizen?
Yes No
If you were not born in Australia, how long have you lived in Australia?
3. Previous employment
Have you previously been issued an equivalent internet gaming key employee
licence issued by a State or another Territory of the Commonwealth? If yes,
give details in the space provided below
Yes No
Name of employer
Position
Duties
Term of employment
Internet Gaming Key Employee Licence
Department of Business
Page 2 of 4
Internet Gaming Key Employee Licence
4. Disclosures
Please complete the following questions. If you answer YES to any of the questions, please provide full
details on a separate sheet as an attachment.
In the Northern Territory or elsewhere have you:
a. Have you ever been found guilty of an offence involving dishonesty
since you have attained the age of 18 years?
Yes No
b. Have you ever been found guilty of an offence against the Gaming
Control Act?
Yes No
c. Have you ever been found guilty of an office that is punishable on
conviction by a maximum penalty of not less than 5 years
imprisonment?
Yes No
d. Do you have any pending offence/charge?
Yes No
e. Are you an undischarged bankrupt or have you ever applied to take
the benefit of any law for the relief of bankrupt or insolvent debtors
compounded with creditors or made an assignment of your
remuneration for their benefit?
Yes No
f. Are you currently associated with or actively participate in the
management or operations thereof as a director, partner or other
capacity of any corporation, partnership, joint venture or business?
Yes No
g. Have you ever held an executive position with any company that has
either been in liquidation or receivership?
Yes No
5. Certificate of Internet Gaming Licensee (person authorised by the Licensee)
I, (insert name)
holding the position of
(insert position)
Licensee / Applicant’s
employer
Hereby certify that the
applicant (insert full name
of applicant)
i. will be engaged, subject to the applicant being granted the internet gaming key employee licence,
to perform key duties in relation to the internet gaming licence; and
ii. investigations and inquiries have been conducted into the probity of the applicant and that the
applicant is competent to perform the duties for which he or she is to be employed.
I have also verified that the applicant:
(a) is of good repute having regard to character, integrity, honesty and responsibility;
(b) has an adequate command of the English language for the purpose of performing
the duties he or she proposes to perform; and
(c) has a sound and stable financial background
If the application is successful, this person will be employed in the
capacity of
Signature
Date
Internet Gaming Key Employee Licence
Department of Business
Page 3 of 4
Internet Gaming Key Employee Licence
6. Supporting documents
The following documents are required to be lodged with this application.
Current photographic identification (copy of current drivers licence or passport)
Evidence of change of name (eg: copy of marriage certificate or deed poll documents) if
applicable
2 passport photographs
Evidence of lodgement of National Police History Name Check conducted within the last
3 months.
(New Application = Fingerprint check; Renewal application = Name check)
The prescribed fee
7. Privacy statement
The Department of Business complies with the Information Privacy Principles scheduled to the
Information Act.
8. Unattested declaration under the Oaths, Affidavits and Declarations Act
I (insert name):
Of
(insert address):
solemnly and sincerely declare that:
1. all statements and information contained in this application for the purpose of obtaining a licence
under the Gaming Control (Internet Gaming) Regulations are true and correct to the best of my
knowledge;
2. I have read and understood the information contained in this application; and
3. I know that it is an offence to make a declaration that is false in any material particular.
I hereby consent to all probity investigations carried out by authorised officers of Licensing NT to verify the
information provided by me and to determine my suitability to hold the licence for which I have applied. I
agree that such inquiries may be made before and after the issue of a licence.
This declaration is made at
(Place)
On (Date)
Signature of Applicant
Note: A person wilfully making a false statement in a statutory declaration is guilty of a crime and is liable
to a penalty or imprisonment, or both.
Internet Gaming Key Employee Licence
Department of Business
Page 4 of 4
Internet Gaming Key Employee Licence
9. Payment options
Contact your local Territory Business Centre for the relevant schedule of fees.
Cash - Territory Business Centre
Cheque - payable to RTM (Receiver of Territory monies)
Credit card
Visa MasterCard
Credit card number
Expiry
Name on card
I hereby authorise the Territory Business Centre to debit the above credit card for
the amount of
$
Amount in words dollars
Signature of cardholder
Date
Contact phone number
10. Lodgement options
Applications can be lodged at a Territory Business Centre with the prescribed fee at:
Darwin
Ground Floor, Development House
76 The Esplanade
Darwin
GPO Box 9800
Darwin NT 0801
t (08) 8982 1700
f (08) 8982 1725
Toll free 1800 193 111
e territory.businessc[email protected]
Katherine
Shop 1, Randazzo Building
18 Katherine Terrace
Katherine
PO Box 9800
Katherine NT 0851
t (08) 8973 8180
f (08) 8973 8188
e territory.businessc[email protected]
Tennant Creek
Shop 2, Barkley House
Cnr Davidson and Paterson Street
Tennant Creek
PO Box 9800
Tennant Creek NT 0861
t (08) 8962 4411
f (08) 8982 1725
e territory.businessc[email protected]
Alice Springs
Ground Floor, The Green Well Building
50 Bath Street
Alice Springs
PO Box 9800
Alice Springs NT 0871
t (08) 8951 8524
f (08) 8951 8533
e territory.businessc[email protected]
