Fillable Printable Greyhound Application Form
Fillable Printable Greyhound Application Form
Greyhound Application Form
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RO05.1 - BOOKMAKER APPLICATION FORM
(Period Ending 30 June, 2016)
COST: $ 198
• Licence to conduct wagering at NSW greyhound tracks • Internet Access • Race Field Information Use
APPLICANT DETAILS
Applicant’s Surname:
Applicant’s First or Given Names:
Residential Address:
State: Postcode:
Telephone Number/s:
Home: Work:
Mobile: Fax:
Email Address:
Date Of Birth: / /
Country Of Birth:
Current Oz Chase Number:
( 6 digit number at the bottom of card)
Do you hold any other wagering licences with any code or controlling body? If yes, please attach a copy. Yes No
BANK ACCOUNT DETAILS
Account Name Bank
BSB No. - Account No.
GST DECLARATION
Are you a Hobbyist? Yes No
Are you registered for GST? Yes No
If Yes, please provide your ABN
WAGERING OPERATIONS
Do you intend to wager on NSW greyhound race meetings while fielding at NSW greyhound race tracks? Yes No
If no, which away race meetings will you be wagering on?
GUARANTEES
1. What was your estimated total turnover for 2014/15?
2. Who is your current guarantee with?
3. What amount is your current guarantee?
4. Do you envisage any material change in 2015/16?
ALL APPLICATIONS REQUIRE
• Police Probity Check
• Certified Colour Passport Size Photo
• Certified Copy of Drivers Licence, Passport or Birth Certificate
• Appropriate Fee (for fee schedule please see
www.thedogs.com.au )
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Do you intend to use Internet Access for the purpose of placing Bet Backs? Yes No
Internet Access is for the purpose of placing bet backs & viewing approved wagering websites while fielding.
Please note a prior approval from Office of Liquor, Gaming & Racing is required.
If yes, please provide details of all wagering accounts:
Wagering Operator Account Name Account Number
WHICH NSW GREYHOUND TRACK/S DO YOU INTEND ON FIELDING?
Appin Gosford Potts Park
Armidale Goulburn Richmond
Bathurst Grafton Tamworth
Broken Hill Gunnedah Taree
Bulli Kempsey Temora
Casino Lismore The Gardens
Coonabarabran Lithgow Tweed Heads
Coonamble Maitland Wagga
Cowra Moree Wauchope
Dapto Mudgee Wentworth Park
Dubbo Muswellbrook Young
Forbes Nowra
PROPOSED USE OF NSW GREYHOUND RACE FIELD INFORMATION
Do you intend to use NSW greyhound race fields for purposes other than to facilitate wagering transactions? Yes No
If yes, please specify those purposes:
KEY EMPLOYEES & CLOSE ASSOCIATES
This section must be completed by applicants in relation to each Key Employee and Close Associate of the applicant as defined by the
Regulations. The Regulation defines each of these terms in the following manner:
Key employee, in relation to an applicant for or holder of an approval, means a person (whether or not a person appointed under a contract of
service) who is:
(a) employed in a managerial or supervisory capacity in relation to the conduct of wagering operations by the approval applicant or holder, or
(b) authorised to make decisions, involving the exercise of his or her discretion, that regulate the operations of the approval applicant or holder
in relation to the conduct of wagering operations, or
(c) concerned or engaged, in any manner, in the conduct of wagering operations by the approval applicant or holder.
A person is a close associate of an applicant for, or the holder of, an approval if the person:
(a) holds or will hold any relevant financial interest, or is or will be entitled to exercise any relevant power (whether in his or her own right or on
behalf of any other person), in the business of the approval applicant or holder, and by virtue of that interest or power is or will be able (in
the opinion of GRNSW) to exercise a significant influence over or with respect to the conduct of that business, or holds or will hold any
relevant position, whether in his or her own right or on behalf of any other person, in the business of the approval applicant or holder.
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A relevant power means any power, whether exercisable by voting or otherwise and whether exercisable alone or in association with others:
(a) to participate in any directional, managerial or executive decision, or
(b) to elect or appoint any person to any relevant position.
A relevant position means the position of director, manager, and other executive position and secretary, however those positions are designated.
If you are not able to complete the details of each Key Employee and Close Associate in the space provided please attach additional
details on a separate paper.
KEY EMPLOYEES & CLOSE ASSOCIATES (Continued)
Name
Role
Has the person been guilty of an offence punishable by fine or imprisonment either in NSW or elsewhere? Yes No
If yes, please provide details including but not limited to the nature
of the offence, the date of the offence and the penalty imposed
Has the person ever been subject to disciplinary action in relation to any legislation/rules of betting or racing? Yes No
If yes, please provide details including but not limited to the nature
of the offence, the date of the offence and the penalty imposed
Name
Role
Has the person been guilty of an offence punishable by fine or imprisonment either in NSW or elsewhere? Yes No
If yes, please provide details including but not limited to the nature
of the offence, the date of the offence and the penalty imposed
Has the person ever been subject to disciplinary action in relation to any legislation/rules of betting or racing? Yes No
If yes, please provide details including but not limited to the nature
of the offence, the date of the offence and the penalty imposed
Name
Role
Has the person been guilty of an offence punishable by fine or imprisonment either in NSW or elsewhere? Yes No
If yes, please provide details including but not limited to the nature
of the offence, the date of the offence and the penalty imposed
Has the person ever been subject to disciplinary action in relation to any legislation/rules of betting or racing? Yes No
If yes, please provide details including but not limited to the nature
of the offence, the date of the offence and the penalty imposed
INTEGRITY OF RACING
1. What measures do you currently enforce to detect suspect
betting transactions or fraudulent activity?
2. Who do you currently report to with respect to suspect betting
transactions or fraudulent activity?
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QUESTIONNAIRE
Have you ever been or are you currently disqualified, suspended, warned off or listed as a defaulter by
any horse, harness or greyhound racing body?
Yes No
Have you, in the last 10 years, been convicted of any criminal offence under your own name or any other
name?
Yes No
Are there any charges or criminal prosecutions now pending against you?
Yes No
Have you under this or any other name ever been charged with or convicted of an offence under the
Prevention of Cruelty to Animals Act?
Yes No
If your answer if “Yes” to any of the above questions, please provide details:
DECLARATION, UNDERTAKINGS & AUTHORISATIONS
I declare that the particulars contained in this form are true and correct and that I understand it is a serious offence under the GRNSW Greyhound Racing Rules and the
Greyhound Racing Act 2009 to make a false declaration and / or provide false or misleading information at any time to GRNSW. I also understand that it is an offence
under the Crimes Act 1900 to provide false or misleading information to GRNSW in this form, punishable by up to two years’ imprisonment or a fine. I agree at all
times to observe and be bound by the Greyhound Racing Act 2009 and the GRNSW Greyhound Racing Rules, all applicable rules and laws in force from time to time
during the currency of my licence / registration and all decisions and directions by GRNSW that it is empowered to make or give. I will advise GRNSW if there is any
change in the particulars in this form. I understand that a failure to disclose full and accurate information to GRNSW when requested by GRNSW as part of its licensing
and supervisory activities may result in GRNSW refusing to approve my application.
PRIVACY POLICY
Greyhound Racing New South Wales ABN 61 018 166 136 (GRNSW) understands the importance of your personal information and its privacy and is committed to
ensuring the privacy of your personal information. By signing this document, you consent to GRNSW collecting, using, holding and disclosing personal information
about you in the manner set out in the Greyhound Racing New South Wales Privacy Policy which is available on www.thedogs.com.au. By signing this document, you
also consent to GRNSW sending documents to you electronically. GRNSW may seek and obtain further personal information (including sensitive information) about
you during our dealings with you. The terms of this consent apply to the collection, use, holding and disclosure of that information as well. You do not have to
supply GRNSW with personal information about you but, if you do not do so, your application may be rejected.
FOR OFFICE USE ONLY
Licence Number: Serial Number: Probity Check Received:
SIGN
HERE
DATE
…… / …… / ……
OFFICE USE ONLY
