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4 Minjungbal Dr, Tweed Heads South
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Please fill out the form below for any suspicous matters you may notice in the gaming area.
Be as specific as possible
You can upload photos toward the end of the form if required
Gaming Suspicious Matter (SMR) form
"
*
" indicates required fields
Step
1
of
9
11%
Please notify a supervior and let them know you are completing this SMR form
Date
*
DD dash MM dash YYYY
Time of report
Hours
:
Minutes
Staff Member Name who is lodging the form:
*
Customer details
Customer Name if known
Member number (if known)
Desription of the individual if name and details are unknown
Did the customer provide ID?
Yes
No
Customer ID (If available)
ID type..
Drivers licence
Passport
Pension card
Proof of age card
Other
other details
State of issue
NSW
QLD
VIC
SA
ACT
TAS
WA
NT
International
Document number
Nationality
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
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Chile
China
Christmas Island
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Cook Islands
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Eswatini
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Namibia
Nauru
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Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
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Palestine, State of
Panama
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Paraguay
Peru
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Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
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Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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Slovakia
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Sudan
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Tanzania, the United Republic of
Thailand
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Virgin Islands, U.S.
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Country
SMR Details
Date of suspicious incident
*
DD slash MM slash YYYY
Time of incident
Hours
:
Minutes
Service type
Gaming
TAB
KENO
Cashier
Other
Approximate amount
less than $1,000
$1,000 - $4,999
$5,000 - $9,999
$10,000+
Location of suspicious incident
What suspicion indicators where observed? (tick all that apply)
Multiple linked transactions
Cash in - minimal play - cash out
Refusal to provide ID
Multiple machines used
Request to avoid reporting
Third-party involvement
Rapid movement between machines
Refused to answer questions
Nervous / evasive behaviour
Multiple people linked to one gaming activity (smurfing)
possible use of proceeds of crime
Customer appears to be avoiding staff observation
Other (describe below with other details)
Describe the suspicious activity
Immediate Actions Taken
Requested customer ID
Refused transactions
Transaction completed for safety reasons
Player activity reviewed
Escalated to Supervisor or Manager
Compliance Officer notified
Police called
No Action
Other (describe below with other details)
Describe the action taken
Any other information you wish to include:
Press select files to take a photo or upload a photo from your phone if required
Drop files here or
Select files
Max. file size: 2 MB.
Was there any CCTV of the event?
Yes
No
Details of CCTV. Time, date, camera etc...
Was gaming data reviewed?
Yes
No
Details of gaming data
Press select files to take a photo or upload a photo from your phone if required
Drop files here or
Select files
Max. file size: 2 MB.
Were any witness statements obtained
No
Yes
Witness name
Witness contact deatils (phone or email)
Witness statement
Staff declaration
I confirm that the information in this report is true and accurate to the best of my knowledge and has been recorded factually
*
I confirm this information
Name
First
Last
Submit
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07 5524 3655
4 Minjungbal Dr, Tweed Heads South
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