get Et QC C. AFTER SO (31111-rf NIG REPORT

get Et QC C. AFTER SO (31111-rf NIG REPORT CARO', f\NErt Mt SURNAME • wo--_-; t.71- e -Nov-leaps swum Government of South Australia Office of the Liquor and Gambling W' s'. Commissioner ri ck6CZOENTED v•JfklYieN )N1 AL/- Re. pog-rs Order Barring Pen From a Licensed Premi: Office of the Liquor and Gambling Commis Level 9. Eost Wing, 50 Grentell Street Adefoide S. GPO Box 2169 Adetilde S. f • w www.c4gc.sa.gov.ou or vnvw.chorfties.so.£ For assistance with this application, refer to 'Burring a Person from a Licensed Premises - Information she( Order barring person from entering or remaining on licensed premises Name of person to be barred Address (if known) Zack; c (Z'oc ctc.) e Ine *Gray No: street: vv suburb/Town: postcode: Under Section 125 of The liquor Licensing Act, you are barred from the following licensed premises Premises name Licence number Address of premises rCerrl-- 11 0 -1- f..-1 5 O 1 0 0 4 S No: 3 0 street: A l ey an d er 5+ suburb/Town: postcode: 551. plc-\\ t. Period of barring (tick one box) El 1 month months (1st barring) 0 6 months (2nd barring) 0 other (please specify) 0 indefinite .44. Period of boning from:?..../ 9 I 16. to 16 If Is an offence if you enter or remain on the specked premises during the specified period (maximum fine $1250.00) If you are barred from a premises for an indefinite period or a period exceeding 1 month, or for periods exceedir month in aggregate, during a 3 month period, you may apply to the Liquor and Gambling Commissioner for a re of the order. The Commissioner on review may confirm, vary or revoke the barring order. Reason for the order la brief description of the offence committed by the person or the offensive or disorderly behaviour of the person or the reasonable grounds and the date, time and place of the relevant incidents) Abc./5;vt.. +co./at-cis 51-afp 5 / fs Licensee/Responsible person's signature: Date: 5 q EFTA00266669 Order Barring Person From Licensed Pren NOTE This order does not operate unti it is served on the person to be barred; • personally: a • if the person hos nominated an address for service then by leaving It or posting it to that address inan envelope adCfre the person; a • by posting it to the person's usual place of business a residence in an envelope addressed to the person; a • by leaving it at or posting It the address of the person's solicitor in an envelope addressed to thot solicitor. A copy of this order must be kept at the (sensed premises to which it relates. If o person is boned fa an indefinite period or a period exceeding 6 months, the Liquor and Gambling Commissioner must days of service receive a copy and detais of this order (in accordance with Section 125 of the Liquor Licensing Act. 1997) fr ficensee/responsible person, or the order will cease to hove effect. Order barring person from entering or remaining on licensed premises PROOF OF SERVICE (to be completed on the copy of the order that is kept of the tensed premises to which it relates) I certify that a duplicate of this order was served on: Name of person to be baited aC, bele, u.thne V ersona 0 Posting to the following address No: street: suburb: postcode: 0 Leaving it at the following address No: street: suburb: postcode: ' CI 16 On: at: 9- tsPt^ (date) (time) Signed: (person effecting the service) EFTA00266670