Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696586103637.pdf (Vanuatu)
VANUATU GOVERNMENT – Corporate Services La Casa D’Andrea Building, Lini Highway, Private Mail Bag 9012, Port Vila, Vanuatu Telephone: (+678) 33010 Email: CIRCorporate@vanuatu.gov.vu Website: http://customsinlandrevenue.gov.vu Application for an Interactive Gaming Licence FOR OFFICIAL USE (Interactive Gaming Act No 16 0f 2000) To Be Sent To: DIRECTOR OF CUSTOMS AND INLAND REVENUE PRIVATE MAIL BAG 9012 PORT VILA VANUATU Tel: (678) 33010 Fax: (678) 22597 Date Received:_____________________________ _______ Approved/Refused by Director:______________________________ Date:_________________________________ Amount of Licence Fee Paid: VT_________________ Receipt Number:______________________________ Date:_________________________________ _______ Interactive Gaming Licence No___________________ Details of Applicant: 1.
Name of applicant:__________________________________________________________________ 2.

Address:__________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 3.

Telephone:_____________________________________ E-mail: 4.
Status of Applicant: _______________________________ (Proprietor, Manager, Secretary, Director etc…) 5.

Nationality of Applicant:_________________________ Passport No____________________ 6.
Date of Birth of the Applicant:_________________________________ 7. Business Constitution Type:_______________________________________________________ (Sole Trader, Partnership, Limited Company, Estate/Trust, Club or Other etc…) 7.1 7.2 Partnerships must provide a copy of the Partnership Agreement Companies must provide company’s register of shareholders and its annual statements Corporate Services Service Organisationnel VANUATU GOVERNMENT – Corporate Services La Casa D’Andrea Building, Lini Highway, Private Mail Bag 9012, Port Vila, Vanuatu Telephone: (+678) 33010 Email: CIRCorporate@vanuatu.gov.vu Website: http://customsinlandrevenue.gov.vu 8. Business or Trading Name:_________________________________________________________ Is this name registered with the Registrar of Business Name?
(Delete as appropriate)  Yes  No Registration number: _____________________ Expiry Date: _________________________ 9.

List any other jurisdictions in which Business Entity is registered or seeking interactive gaming or betting registration.

10.

Has the Business Entity ever applied for and been refused registration in any matter or a license or certificate including a gaming and betting license, in any jurisdiction?

Yes………………….. /No…………………….

If yes, please give details on an attachment page.

11.
11.

Has the Business Entity ever had any license revoked, including Interactive Gaming?

Yes………………….. /No…………………….

If yes, please give details on an attachment page.

12.

Has the Business Entity ever been convicted of a betting, Gaming, Casino, Customs or Tax Offence Either in Vanuatu or in an Overseas Country?

 Yes  No (Delete as appropriate) If yes, please attach statement giving full particulars of offence, conviction date, location and penalty imposed.

13.
13.

Provide License Certificate or Registration Number(s) or other documents for jurisdiction(s) in which Business Entity is registered.

14.

Address of the Registered Office ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 15.
Address of principal place of business (if different from registered address) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 16.
Mailing address (if different from registered address) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Corporate Services Service Organisationnel VANUATU GOVERNMENT – Corporate Services La Casa D’Andrea Building, Lini Highway, Private Mail Bag 9012, Port Vila, Vanuatu Telephone: (+678) 33010 Email: CIRCorporate@vanuatu.gov.vu Website: http://customsinlandrevenue.gov.vu 17.
Telephone and E-mail address ________________________________________________________________________ ________________________________________________________________________ 18.

Is the Business Entity a member of the International Gaming Council or any other International Gaming or Betting Association or any other gaming associations?

 Yes  No 19.

Provide details of the source of funds used to pay the capital of the business on an attachment page 20.
Provide the full name, address, nationality and date of birth of each of the beneficial owners, controllers, directors and managers of the entity seeking an interactive gaming license?

20.1 Complete a Personal Information Form for each beneficial owner, owner, controller, director and manager.

20.2 Disclose (if any) beneficial owners are beneficial owners, owners or controllers of another regulated entity in Vanuatu or in a foreign country?

21.
21.

This application must include: 21.1 A completed “Company Probity Form” (if applicable) in respect of the applicant 21.2 21.3 A copy of your Business Plan.

Prescribed fee DECLARATION (if applicable): In the case of a Company/Body Corporate, I/we certify that I/we am/are duly authorised to make the application on behalf of the Company/Body Corporate.
Executed under the common seal of........................................................................................... (If applicable) (Name of Company/Body Corporate) (Company Seal) Signature ___________________________________________ Name:______________________________________________ (Please Print) Corporate Services Service Organisationnel VANUATU GOVERNMENT – Corporate Services La Casa D’Andrea Building, Lini Highway, Private Mail Bag 9012, Port Vila, Vanuatu Telephone: (+678) 33010 Email: CIRCorporate@vanuatu.gov.vu Website: http://customsinlandrevenue.gov.vu Applicant Name Applicants Signature Date In the presence of___________________________________ (Signature of Witness) Name of Witness______________________________ Address of Witness: ............................................… ............................................… ............................................… ............................................… Corporate Services Service Organisationnel