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(Section 42)

Application For Consent To Sell, Let On Hire Of

Otherwise Dispose Of A Gambling Machine

Or Any Interest Therein

1. Full name of applicant……………………………………………………………

2. Address of applicant……………………………………………………………..

3. Nationality of applicant…………………………………………………………..

4. Make of machine………………………………………………………………….

5, Serial No…………………………………………………………………………..

6. Nature of proposed transaction………………………………………………….

………………………………………………………………………………………

7. Nature and address of proposed buyer/hirer/consignee……………………

…………………………………………………………………………………….

…………………………………………………………………………………….

8. Nationality of proposed buyer/hirer/consignee………………………………

9. Present location of machine:

(2) Name of premises………………………………………..

(3) Town or city………………… ………………………….

10. Proposed location of machine:

(a) Name of premises………………………………………..

(b) Town or city………………… ………………………….

11. Number of present gambling machine license (if any)……………………..

12. Date of expiry of present licence……………………………………………..

I CERTIFY that I am the true owner of the gambling machine in respect of which this application is made and that the particulars given in the application are true.

……...…………………..

Signature of applicant

…………………………….20………