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Order form

Replacement competency card

Office use only Form ID-CC0500
Use this form to apply for a replacement card if your
card has been lost, stolen or damaged or you have By mail OTC email
changed your name
Date lodged / /
Do not use this form if your card has expired. You
must complete a new course. Amount paid $
Receipt number
Information for applicants
Application number
1. Complete all applicable questions. If information
Finalised by
is missing, we can ask you to supply the required
information and/or documents to support the Date finalised / /
application. Failure to supply information can delay
the processing of your order. Notification issue date / /

2. The fee for a replacement card is $30
3. Allow 3-4 weeks for processing and delivery of your replacement card
4. If you need help in completing this application, call (02) 9995 0900 between 9am and 4pm or email
5. For more information visit
6. This form can be completed on a computer, using Adobe Reader or Adobe Acrobat. It should be saved to
your computer and then attached to an email or printed. If completing by hand, please print all answers in
capital letters.
7. Lodge this application form with payment by:

Email Post Deliver to Competency Cards Liquor & Gaming NSW
(credit card payment only) Liquor & Gaming NSW Level 6, 323 Castlereagh St
GPO Box 7060 Haymarket NSW 2000
Sydney NSW 2001 Hours: 9.00am-5.00pm

Important note
You cannot work without a valid competency card if your work involves any of the following:
• selling, serving or supplying alcohol, or working with gaming machines in hotels and clubs in NSW
• being an RSA marshal or security guard in the liquor or gaming industry
• staffing an ID scanner in Kings Cross

Replacement competency card | CC0500 | May 2016 1 of 4

Replacement competency card Part 1 Card holder details What is your current full name?: Title (eg. Mrs) Given name Middle name(s) Family name Does your card require a name change?: No Yes If Yes. enter name currently shown on card (please attach/provide proof of change of name: Change of Name certificate (Registry issued). or Australian Divorce Papers (Family court issued) Date of birth (dd/mm/yy) Email Phone Postal address (this is the address your replacement card will be sent to) Street address or PO Box Suburb State Post code Part 2 Existing competency card details Card number (if known) Competencies listed on card (tick all that apply) RSA (Class A) RCG (Class G) Privacy (Class P) Replacement competency card | CC0500 | May 2016 2 of 4 . Marriage Certificate (Registry issued or Foreign translation). Mr.

• I acknowledge that it is an offence to provide false or misleading information. FULL NAME SIGNATURE DATE PAYMENT DETAILS ARE ON THE NEXT PAGE Replacement competency card | CC0500 | May 2016 3 of 4 . • I acknowledge that the failure to provide all required information may result in an inability to process this application or a delay in the processing of this application. • I understand that specific details I have provided may be ‘personal information’ under the Privacy and Personal Information Protection Act 1998. and that I have made all reasonable enquiries to obtain the information required to complete this form.Replacement competency card Part 3 Reason for card replacement Please provide the reason(s) you require a replacement competency card (tick all that apply) lost card card stolen card damaged card never received change of name other reason (please describe): Part 4 Declaration • I declare that the information I have provided is true. correct and complete.

jpg) or Use Certificate and follow the instructions on screen. Replacement competency card | CC0500 | May 2016 4 of 4 .Replacement competency card Part 5 Payment Details A fee of $30 is payable for a replacement competency card.* Pay the applicable fee by: Credit Card* Cash (in person only) Money Order Cheque Payment amount* $ For credit card payments: * Card type: Mastercard Visa Card number Expiry CCV The CCV is the last 3 digits printed on the signature panel on the back of your card. Use Image (to insert an image file such as a . A surcharge is applicable if paying by credit card.4% is added to the payment amount if paid by credit card. Draw. select Place Signature then choose between Type. Card holder’s name Card holder’s signature To insert signature click Sign or Fill & Sign at the top right of the page. For cheque payments: Make cheques payable to Liquor & Gaming NSW Cheque drawer’s name *Note: Under NSW Government policy a surcharge of 0.