Order
of gaming machine operating ability certification pursuant to Act No. 202/1990, Collection of Laws, on lotteries and other similar games, as amended, and on amendments of further acts.	

order registration number		order number										
	to be filled in by client	sample number										
do not fill in - to be completed by ITC
Client:
Business company:	DIČ													
	IČ									
Companys address:		Phone		
		Fax		
Postal code							e-mail		
Registered in Companies  Register at:		
Person authorized to discuss contractual matters:	Person authorized to discuss technical matters:	
		
Banking with:		
DIČ = VAT registration number	IČ = company registration number
GAMING MACHINE - MANUFACTURER:
Hardware (gaming machine cabinet)	Gaming machine software	
Type:		Model - game:		
Manufacturer:		Software version:		
Address:		Producer:		
		Address:		
Date of manufacture (month and year indicated by the manufacturer: 			
			
Serial number:				
Fact decisive for assessment of the gaming machine		
Maximum amount of money bet on one game:		Maximum possible winning in one game:		
Winning share set:		
The gaming machine has a system of double check of paid-in and paid-out money: *		Yes	No	
A Conformity Declaration has been issued for the gaming machine within the intention of Act No. 22/1997, Collection of Laws:*		Yes	No	
	*) Delete which is not applicable	
Send the completed Order to ITC or GMT Europe*) for each model (game) and enclose the documents as follows:	
a)	A detailed description of the game and game plan in the Czech language confirmed by the Client specifying game conditions, particularly type of the gaming machine, maximum bet and maximum winning in one game, winning share set, method of money pay-in and pay-out as related to kind of coins used.	
b)	Two originals of the memory element  (EPROM,CD, etc.) indicated by the manufacturer.	
c)	Statistical statement of the game including winning share course (100 000 games-step 1000 games) carried out at minimum and maximum value of winning share set and at minimum and maximum value of bet.	
d)	Diskette with statement of software source code. 	
e)	Statement of hardware (cabinet) manufacturer on date (month, year) of gaming machine manufacture.	
f)	Software producers confirmation of and statement on conformity with already registered software version for the Czech Republic. 	
g)	Description of set-up of all DIP-DIL switchers confirmed by software producer.	
h)	Graphical display of front glasses.	
	The documents shown in points b), d) must be submitted complete with the statement on the ITC form. 
	In case of a repeated certificate only documents indicated in points a), e), f) must be presented. 
	In case of an order for assessment of a larger number of gaming machines of identical type and identical model (game) the data can be given on the reverse side of the order.	
*) GMT Europe, a.s., Praha 9 – Vysočany, Business Centrum Ocelářská, Ocelářská 35, Phone: +420 284 080 270 - 2,  
Cell phones: +420 605 297 287, +420 737 910 788, Fax: +420 284 080 272, e-mail: sebesta@gametest.cz 	
Date:				
	Name and signature of Clients authorized representative (imprint of rubber stamp)