City of Joondalup Forms – A Global City: Bold | Creative

22:22:58

Application for a Gaming Permit (Section 55) – Health & Environmental Services

Applicant Details
Applicant Type*
- Not for profit group
- Commercial applicant
Group / club / business name*
ABN / ACN*
Contact person*
Given Name(s) Surname
Postal Address*
Street Address Suburb State Post Code
Phone Number*
Email*
Gaming Details
Premises Name
Event Name
Gaming Activity
Address of event*
Single / Recurring event*
- Single Event
- Recurring Event
Event Date*
DD slash MM slash YYYY
Period Start Date*
DD slash MM slash YYYY
Period End Date*
DD slash MM slash YYYY
Event Start Time*

Hours :

Minutes

AM/PM
Event Finish Time*

Hours :

Minutes

AM/PM
Days of gaming (select as many as applicable)*
I understand that an Environmental Health Officer may inspect the premises to check for compliance with the relevant legislative requirements.*
- Yes
Payment Details
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payment_process_mode
NOTE: THE PAYMENT PROCESSING CONTROLS ON THIS FORM ARE CURRENTLY SET FOR TEST MODE
(Use either 5555444433331111 or 4444333322221111 for the Credit Card No. with 111 as the CCV)
Payment Type Code
Fee (GST N/A)*
Price:
Fee (GST N/A)*
Price:
Total (GST N/A)
$ 0.00
This field is hidden when viewing the form
GST info
This field is hidden when viewing the form
Payment Type
Credit Card*

MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Comments
This field is for validation purposes and should be left unchanged.

Applicant Details