RSA/RCG

Order form

Replacement competency card

Important
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
competencycard@olgr.nsw.gov.au
5. For more information visit www.liquorandgaming.justice.nsw.gov.au/Pages/liquor/serving-alcohol-
responsibly/competency-cards.aspx
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

competencycard@olgr.nsw.gov.au 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

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Replacement competency card

Part 1 Card holder details

What is your current full name?:

Title (eg, Mr, 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), Marriage Certificate (Registry issued or Foreign
translation), 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)

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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, and that I have made all reasonable
enquiries to obtain the information required to complete this form.
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 acknowledge that it is an offence to provide false or misleading information.
I understand that specific details I have provided may be personal information under the Privacy and Personal
Information Protection Act 1998.

FULL NAME

SIGNATURE DATE

PAYMENT DETAILS ARE ON THE NEXT PAGE

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Replacement competency card

Part 5 Payment Details

A fee of $30 is payable for a replacement competency card. A surcharge is applicable if paying by credit 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.

Card holders name

Card holders signature

To insert signature click Sign or Fill & Sign at the top right of the page, select Place Signature then choose between Type, Draw, Use Image (to insert an
image file such as a .jpg) or Use Certificate and follow the instructions on screen.

For cheque payments:

Make cheques payable to Liquor & Gaming NSW

Cheque drawers name

*Note:
Under NSW Government policy a surcharge of 0.4% is added to the payment amount if paid by credit card.

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