AUTHORISATION FOR RELEASE OF INFORMATION
To, and without exception, both domestic and foreign, all Government departments and
agencies, Employers, Educational Institutions, Courts, Banks, Financial and other such institutions
and any other third party that may hold information.
I,
(please complete your name in full in capital letters)
Date of Birth:
Signature:
Hereby authorise the Gambling Commission, its officers or agents to undertake such enquiries
and request, receive and obtain any and all information, including copies of any record,
documentation or opinion whether in written, electronic or any other form, that the Gambling
Commission may require when considering the suitability of the individual (either in application
of a licence or as a person considered by the Gambling Commission to be relevant to an
application), both upon application for any licence, and, if so granted, throughout the life of any
licence.
This authorisation shall supersede and countermand any previous request or authorisation to the
contrary. A photocopy or electronic version of this authorisation will be considered as effective
and as valid as the original.
Date:
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