Gaming Machine License Application & renewal Checklist

SECTION 1 – APPLICANT'S GENERAL INFORMATION

Gaming Machine Route

Slot Parlour

APPLICATION TYPE

New

Renewal

Gaming Machine Route

APPLICATION #

PERSONAL INFO

NAME

BIRTH DATE

PHONE

ADDRESS *

HOME ADDRESS

CITY

COUNTRY

WORK ADDRESS

Nationality

NIB NUMBER

OCCUPATION

HAVE YOU EVER MADE AN APPLICATION FOR A GAMING LICENSE IN THE TCI OR OWED A GAMING LICENSE? IF YES PROVIDE DETAILS

SECTION 2 – BUSINESS INFORMATION

NAME OF BUSINESS: (Where machines will be located – Prescibed Premises)

BUSINESS ADDRESS

NATURE OF BUSINESS

BAR

NIGHT CLUB

GAMING PARLOUR

Other

ROUTE MANAGEMENT COMPANY NAME:

LIQUOR LICENSE No.

BUSINESS LICENSE No

CHECK IF PREMISES IS

OWNED

LEASED

PROVIDE LANDLORD NAME,ADDRESS AND PHONE NUMBER

TO WHO IT MAY CONCERN

1. I have made an application to the Gaming Inspectorate of the Government of the Turks and Caicos Islands for a Certificate of Approval/Gaming License under section 3 of the Gaming Machine Ordinance amended 2014. I hereby give my authorization to any and all persons or organizations, including Police, Banking institutions,s and Licensing authorities, for the release of any information regarding me, whether of written record or otherwise, to furnish such information to the Gaming Inspectorate official, on request.

2. In connection with my application, I shall not hold any person or organization responsible in any way for the information which they furnish relative to me, whether such information is oral or written. Further, I will not hold any person or organization liable for any publicity which may arise out of my application to the Gaming Inspectorate.

Date

Name in Capitals

Passport No.

Contact No.

Address

Signature

*This Document must be notarized by a justice of the peace.

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