(Section 43(2))

Application For License To Install Or Operate

A Gambling Machine

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

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

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

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

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

6. Date of importation……………………………………………………………...

7. Particulars of Import Licence…………………………………………………..

(Attach copy)

8. Country of origin………………………………………………………………..

9. Cost of machine………………………………………………………………..

10. Customs duty paid……………………………………………………………...

(State amount, quote receipt Number and attach

Copy of receipt it available)

11. Income Tax Clearance Certificate No…………………………………………

(Attached copy)

12. Particulars of previous licence:

(a) Number…………………………………………………………..

(b) Issued by…………………………………………………………

Fee paid GH¢……………………………………………………………

Date of expiry…………………………………………………………..

13. Present location of machine:

(a) Name of premises………………………………………..

(b) Town or city………………… ………………………….

14. Proposed location of machine:

(a) Name of premises………………………………………..

(b) Town or city………………… ………………………….

15. Is proposed location owned by applicant? – Yes / No

16. If “No” state how location is acquired………………………………………

………………………………………………………………………………….

(Attach agreement or evidence of allocation of location)

17. Total number of gambling machines at present owned by the applicant

…………………………………………………………………………………

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………