Gambling dispute form

Required fields are marked with an asterisk (*).

Your personal details

Title *

First name *

Family name *

Address *

Email *

Telephone *

Check if yes

Are you making this report on behalf of someone else? If yes, please provide details

Someone else details Dispute must be lodged by the account holder in first instance. If lodging on behalf of other party or not the holder of an account please provide supporting material or an authority to act on their behalf.

Betting account details

Name of licensed Australian wagering operator *

Betting account name / number / ID *

Nature of complaint

Nature of your complaint * What is the nature of your complaint (for example, refusal to accept fixed odd bet, account closure, refusal to open account, restriction placed on account)? Please provide details.

Details of contact * Prior to submitting this form provide details of the contact made with the wagering operator and outcome of the enquiry and include reasons given.

Documentation to outline the nature of your complaint If you need to add documentation to outline the nature of your complaint, please upload below. Allowed extensions (.pdf, .docx, .doc, .xls, .xlsx). File size limit of 3MB.

Bet details

Event

Race number

Details of bet * Include competitor(s), bet type, stake and price.

How was the bet placed? If 'other' is selected, please specify.

Date bet was placed * Dispute must be lodged within 14 days of the event. If outside of this period, an application for 'out of time' consideration must accompany this dispute.

Application for 'out of time' consideration Application for 'out of time' consideration must provide details of circumstances that warrant the acceptance of the dispute otherwise out of time. Provide attachment if applicable.

Attachments for 'out of time' Allowed extensions (.pdf, .docx, .doc, .xls, .xlsx). File size limit of 3MB.

Attachments and other information

Please provide copies of all evidence Please provide copies of all evidence you seek to rely upon in support of your dispute. This includes all relevant correspondence, copies of betting slips, statement and the like which may assist in the investigation.

Atachments for copies of all evidence Allowed extensions (.pdf, .docx, .doc, .xls, .xlsx, .png, .jpg, .gif). File size limit of 5MB.

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

Photo identification Please specify and attach a copy of one form of photo identification to this report. For example, drivers licence, passport, if other, please specify.

Attachments for photo identification Allowed extensions (.pdf, .docx, .doc, .xls, .xlsx, .png, .jpg, .gif). File size limit of 5MB.

Are you licensed? Are you licensed by any Australian racing body? If yes, please provide details. For example, Racing NSW - Bookmaker, Racing QLD - Trainer.

Are you employed by any Australia wagering operator? Are you employed by any Australia wagering operator? If yes, enter name of wagering operator and in what capacity.

Declaration, acknowledgements and agreements

Full name *

Date *

Place (city or town) *

Please tick both statements before submission

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 content or omission)
By ticking this box I acknowledge and agree that:

- I indemnify and will keep indemnified NT Racing Commission against any loss arising out of, relating to or in connection with any information and documentation I provide to NT Racing Commission 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.

Last updated: 26 July 2022

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