MINIMUM BET LIMITS COMPLAINTS REPORT

Your Personal Details

Select List

First Name *

Family Name *

Address *

Email Address

Telephone

Preferred Contact Medium

Are you making this * Report on behalf of someone else? *

If yes, provide their name, address and your relationship to that person.

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BETTING ACCOUNT DETAILS

Name of Licensed Australian Wagering Operator Name of Licensed Australian Wagering Operator

Betting Account Name/Number/ID

Beneficiary Owner of Betting Account and Bet (if applicable)

What is the nature of * your complaint? (e.g. refusal to accept fixed odds bet, account closed, refusal to open account, restrictions placed on account). Please provide details. *

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NATURE OF COMPLAINT

What is the nature of * your complaint? (e.g. refusal to accept fixed odds bet, account closed, refusal to open account, restrictions placed on account). Please provide details.

Prior to submitting this form provide details of the contact made with the Wagering Operator and the outcome of your inquiry and include reasons given. *

Provide attachments if applicable

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BET DETAILS (complete if your complaint relates to refusal to accept a fixed odds bet)

Date

Race clubs / Tracks Race clubs / Tracks

Race Number

Details of Bet:* include Horse Number and Name: Stake and Price *

How was bet placed?

Was the Bet a Bet Back ( only applies to bets transacted between Wagering Operators )?

Time Bet was Placed * *

(hour,minute,seconds,fractions)

Time Bet was replied by Wagering Operator * *

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ATTACHMENTS AND OTHER INFORMATION

Please list any other documents that may assist in our investigation and attach copies of those documents to this Report. This should include any written communication to/from the Licensed Australian Wagering Operator.

File Upload

Is there any other information that may assist in our investigation? If yes, please provide details.

Please specify and attach a copy of one form of photo identification to this Report.

Driver's Licence, Passport, If Other, Please specify

Are you licensed by any Australian Racing body (Provide details)?

e.g. Racing NSW - Bookmaker, Racing QLD - Trainer

Are you employed by any Australia Wagering Operator? If yes, name of Wagering Operator and in what capacity?

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DECLARATION, ACKNOWLEDGEMENTS AND AGREEMENTS

Full Name *

Date *

Dated:DD/MM/YYYY

Place (city or town): *

Checkbox 1 *

By ticking this box I declare that the information given in this Report and any attached document is true and correct and not false or misleading (in either its contents or by omission).

Checkbox 2 *

By ticking this box I acknowledge and agree that: • I indemnify and will keep indemnified Racing NSW against any loss arising out of, relating to or in connection with any information and documentation I provide to Racing NSW about my complaint that is untrue, incorrect, misleading or false. • An incomplete Report may delay the investigation into my complaint and I may be asked to complete a new Report and/or provide further information. • The information provided in this Report or subsequently provided by me may be used to investigate or otherwise deal with my complaint and may be used in any subsequent Court proceedings relating to my complaint. • I may be called as a witness and required to give evidence under oath in any subsequent Court proceedings relating to my complaint. • Racing NSW may refer my complaint and the information provided by me to another party including a government agency for the purpose of resolving the complaint.

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THIS FORM MUST BE PRINTED AND SIGNED BY THE APPLICANT

Form Dated

Dated:DD/MM/YYYY

Place

City or town

Signature *

Please attach a copy of one form of photo identification to this Report (e.g. your driver licence).

Once you click on submit and print the Complaints Form a pop up message at the top of the web page will confirm the Report has been submitted to Racing NSW.

Please return the signed form to: Race Fields, Level 7, 51 Druitt Street Sydney NSW 2000 or email to mbcomplaints@racingnsw.com.au

Your Personal Details

BETTING ACCOUNT DETAILS

NATURE OF COMPLAINT

BET DETAILS (complete if your complaint relates to refusal to accept a fixed odds bet)

ATTACHMENTS AND OTHER INFORMATION

DECLARATION, ACKNOWLEDGEMENTS AND AGREEMENTS

Racing NSW Apps

Contact

Forms

Information

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