Application for a Licence to Operate or Market Amusement Machines List of documents to be enclosed with the application List of documents to be retained at all times Guide Application for a Licence to Operate or Market Amusement Machines form Appendix A Machine Register Appendix B Personal Information on the applicant, partners and shareholders
Application for a Licence to Operate or Market Amusement Machines IMPORTANT As requested, we enclose the Application form for a licence to Operate or Market Amusement Machines and its guide. Please note that fees are payable in cash, by certified cheque only or by money order to the order of the Régie des alcools, des courses et des jeux and must be attached to the licence. Further, you may now pay your fees by credit card Visa, MasterCard or American Express. Thank you for your co-operation Customer Service Encl. For payment by credit card, please attach this page to your form Visa MasterCard American Express Amount paid Surname and given name of the credit card holder Card number V-Code* Card expiry date (MM/YY) Signature: * The last three digits appearing on the back of the card. 560, boulevard Charest Est, Québec (Québec) GK 3J3, Telephone: 48 643-7667 or 800 363-0320, Fax: 48 643-597, racj.quebec@racj.gouv.qc.ca, rue Notre-Dame Est, bureau 9.0, Montréal (Québec) H2Y B6, Telephone: 54 873-3577 or 800 363-0320, Fax: 54 873-586, racj.quebec@racj.gouv.qc.ca Hearing-impaired: Québec: 48 528-7666, Elsewhere in Québec: 877 663-872 Internet: www.racj.gouv.qc.ca
Application for a Licence to Operate or Market Amusement Machines List of documents to be enclosed with the application List of documents to be retained at all times In order to simplify its procedures for issuing amusement machine licences and seals, the Régie des alcools, des courses et des jeux informs you that you must attach to your application only the following documents:. Machine Register; 2. Appendix B (Personal Information) duly completed and signed under solemn declaration for each partner or shareholder holding 0% or more of the shares bearing full voting rights; 3. Invoices or documents relating to the acquisition of the amusement machines. A proxy, a power of attorney or any other document establishing the capacity of the representative to sign and/or act on behalf of the applicant; The certificate constituting and/or registering the corporation or legal person; Copy of the liability insurance policy; Financial statements; The up-to-date register of amusement machines. GUIDE The Régie wishes to offer the best possible service. We have therefore prepared this guide to help you complete your application for a licence to operate or market amusement machines. We recommend that you read it carefully and assemble all the required documents. Identification of Applicant Check the correct box for the category of applicant. If the application is made in your name (person of full age), give the name that appears on your birth certificate. If the application is made on behalf of a legal person (private or public person or person governed by the Cooperatives Act), indicate the name that appears on the deed of incorporation (letters patent). If the application is made on behalf of a partnership (two persons or more), indicate the name of each partner. If the application is made on behalf of a legal person, sole proprietorship, or partnership, also enter the registration number issued by the Québec Enterprise registrar. 2 Identification of Mandatary If this application is being made on behalf of a legal person, a partnership or a third party, enter the name and address of the person who is acting on behalf of the applicant. 3 Calculation of Fees and Identification of Machines in Storage and Made available to the Public Licence fees are $222, except in the case of a non-profit organization, in which case, the fees are $3.75. Indicate the number of machines in your possession, the number of machines stored in warehouses (that are not made available to the public) and the number of machines made available to the public, then enter the totals of each column. These totals should match the information provided in Appendix A Machine Register. Next, calculate the amount to be enclosed with your licence application, using the following method: The number of machines made available to the public multiplied by the fees. Enter the total in the column Total per Category. Then add the totals for each category and enclose this amount with your application, by certified cheque, money order or credit card to the order of the Régie des alcools, des courses et des jeux. (continued overleaf) 560, boulevard Charest Est, Québec (Québec) GK 3J3, Telephone: 48 643-7667 or 800 363-0320, Fax: 48 643-597, racj.quebec@racj.gouv.qc.ca, rue Notre-Dame Est, bureau 9.0, Montréal (Québec) H2Y B6, Telephone: 54 873-3577 or 800 363-0320, Fax: 54 873-586, racj.quebec@racj.gouv.qc.ca Hearing-impaired: Québec: 48 528-7666, Elsewhere in Québec: 877 663-872 Internet: www.racj.gouv.qc.ca
4 Liability Insurance Appendix A If liability insurance is required, indicate the amount of this insurance, the expiry date, the name of the insurance company and the policy number. The Régie may require that a person wishing to obtain an operator s licence, or who holds one, shall have and maintain a liability insurance policy when: (a) the amusement machines that he wishes to make available or makes available to the public is likely to cause bodily or material damage to those using it or any other person present in a place where such a machine is being operated; (b) the place where an amusement machine is made available to the public involves risks to those present there. 5 Affirmation of Signatory The person making the application or the attorney shall enter in the appropriate place his family and given name in block letters and sign under solemn declaration the licence application. Register of Amusement Machines Manufacturer s Serial Number: Enter the manufacturer s serial number appearing on the machine. House Serial Number: Enter the serial number you have assigned to the machine, if any. Category: Indicate the category of the machine, B, C or D. Condition: Enter the condition of the machine: that is, whether it is in operation (made available to the public), has been seized or is in storage. Each machine in operation (made available to the public) shall bear a valid seal. Manufacturer: Indicate the name of the manufacturer of the machine. Machine Model: Indicate the name of the machine model. of Acquisition: Indicate the date on which you became the owner of the machine. on Which the Machine was Made available to the Public: Indicate the date on which the machine was made available to the public. 6 Solemn Declaration Section reserved to the person authorized to receive the solemn declaration (example: notary, lawyer, postmaster, bank manager, etc.). Appendix B Personal Information on the Applicant, Partners or Shareholders This appendix must be completed by the applicant or by each partner or shareholder holding 0% or more of the shares bearing full voting rights. Please find below, for your information, a table indicating the fees payable for an amusement machine registration seal. This table also includes references to the Regulation respecting amusement machines, which you can obtain from the Régie. Fees Payable for a Registration Seal Brief Description of Machines Category Fees Reference to Payable Regulations Pinball machines B $33 2.3, 2, (a) Machines that may offer a chance to win additional playing time B $33 2.3, 2, (b) or free games (video) and (c) Group of machines operating independently constituting a single B $33 2.3, 2, (d) inseparable group and not offering any gain Game of skill, individual, of manufacture other than handmade B $33 2.3, 2, (d) Game of skill permitting competition among players B $33 2.3, 2, (e) Billiard, pool or snooker table, bowling alley, Air Hockey, C $ 2.3, 3, (b) soccer or other game of same type and (c) Machines aiming only at amusement and not offering any chance C $ 2.3, 3, (d) to win additional playing time, free games or prizes Rides for adults C $ 2.3, 3, (a) Handmade individual game of skill C $ 2.3, 3, (e) Rides for children D $28.75 2.3, 4, (a)
Application for a Licence to Operate or Market Amusement Machines A Identification of Applicant Who is making this application? Yourself A legal person A partneship B C A non-profit organization Type of licence being applied for: Operator s Licence Marketing Licence Name: Sex: F M of Birth Number, Street: City: Province: Postal code Telephone: Work Home Fax area code area code area code Québec Business Registration Number 2 Identification of Mandatary Name: Sex: F M of Birth Number, Street: City: Province: Postal code Telephone: Work Home Fax area code area code area code 3 Calculation of Fees and Identification of Machines in Storage and Made available to the Public Category Number of Machines Owned Number of Machines in Storage Number of Machines made available to the Public Fees Total per Category Licence x $222 = $ 222 Seals B x $33 = $ Seals C x $ = $ Seals D x $28.75 = $ TOTAL $ Amount to be Enclosed with Your Licence Application (Certified Cheque or Money Order) 4 Liability Insurance The applicant maintains a liability insurance policy for $ Name of Insurance Company: that expires on Policy No.: 5 Affirmation of Signatory I, the undersigned, undertake surname and given name (in block letters) To place registration seals only on category B, C or D machines as defined in article 2.3 of the Regulation respecting amusement machines (R.S.Q., c. L-6, r.) and more fully described in the registers filed under this application; To move the machines that are in my possession, if any, for any examination which the Régie may deem necessary or useful, to the place and on the date that it may prescribe; To keep at all times all documents required and submit them to the Régie on request; and affirm: That I am the applicant or I am the mandatary of the legal person or partnership indicated in section ; That all facts and information provided herein are true and accurate. And I have signed: signature 6 Solemn Declaration (Section reserved to the person authorized to receive the solemn declaration) Space reserved to the Régie Solemnly declared before me at on this day of signature of the person authorized to receive the solemn declaration commission number
Appendix A Machine Register Register of Amusement Machines Manufacturer s Serial No. Condition When House Other (In operation Acquisition Machine was Serial No. Serial No. seized, Manufacturer Machine Model Made available (If any) (If any) in storage) year/month/day to the Public year/month/day Category 2 3 4 5 6 7 8 9 0 2 3 4 5 6 7 8 9 20
Appendix B Personal Information on the applicant, partners and shareholders Making an Application for a Licence to Operate or Market Amusement Machines BEFORE COMPLETING THIS APPENDIX Make as many copies as there are partners or shareholders (holding 0% or more of the shares giving full voting rights.) Identification of Applicant, Partner or Shareholder Family and Given Name: Canadian Citizen: Yes No Number, Street: of Birth City: Province: Postal code Telephone: Work Home Fax area code area code area code 2 Offences against the Act respecting lotteries, publicity contests and amusement machines, or the Regulation or Rules respecting amusement machines Have you in the past three years been found guilty of an offence against the Act respecting lotteries, publicity contests and amusement machines, or the Regulation or Rules respecting amusement machines? Yes No If YES, complete this section. Description of offence Description of sentence of Indicate whether the (conviction) conviction sentence was served 3 Offences Against the Criminal Code Have you, in the past three years in the case of an offence punishable on summary conviction or in the past five years in the case of a criminal act, been found guilty of an offence set out in Part VII of the Criminal Code relating to gaming and betting, Part IX relating to offences against rights of property, or Part X relating to fraudulent transactions relating to contracts and trade? Yes No If YES, complete this section. Description of offence Description of sentence of Indicate whether the (conviction) conviction sentence was served 4 Duties of the Signatory If you are the person authorized to act on behalf of the legal person, an administrator or shareholder, check the box corresponding to your situation. - President 2- Vice-president 3- Secretary 4- Treasurer 5- Secretary-treasurer 6- Shareholder 7- Administrator 8- Other (specify): 5 Affirmation of Signatory I, the undersigned, affirm that all the facts and information provided surname and given name (in block letters) herein are true and accurate. And I have signed: signature 6 Solemn Declaration This section is reserved to the person authorized to receive the solemn declaration. Solemnly declared before me at, this day of. signature of the person authorized to receive the solemn declaration commission number Régie des alcools, des courses et des jeux-700b.ang (7-0)