/ RECEWEDOD AFTER SOBMITTING REPORT “CRAY” NET MY SURNAME + WAS NoT ABLSIVE TOhARDS STAFF fT Government of South Australia Order Barring Pers 2 a <= Office of the Liquor and Gambling From a Licensed Premi Ori Commissioner Otis of the Uguerane Gewising Conn FREQUENTED ~ WRITTEN IN ALE REPORTS . el FONG. OCR eet ide S t w www.olgc.sa.gov.au or www.charities.sa.¢ For assistance with this application, refer to ‘Barring a Person from a Licensed Premises - Information shee Order barring person from entering or remaining on licensed premises Sackie (Sac veline "Gra Name of person to be barred Address {if known) postcode: Under Section 125 of The Liquor Licensing Act, you are barred from the following licensed premises “ence namie istol) Jol elajy fs | Address of premises Period of barring OO i month O other (please specify) {tick one box) 3 months (1st barring) 1 émonths (2nd baring) 11 indefinite 96 Petiod of baring from: .2../ <4 It is an offence if you enter or remain on the specified premises during the specified period (maximum fine $1250.00) If you are barred from a premises for an indefinite period or a period exceeding | 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 . . (a brief description of the offence AbvSive + S 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) licensee/Responsible person's signature: ............ - ‘ anes sesassusssentansscassenees soosssssvantsaeesmsnrecnesseeencosees % .Date: 32, ! EFTA00266669

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Order Barring Person From Licensed Pren NOTE This order does not operate until it is served on the person to be barred; * — personally; or . Fa ee SAAN ARLE SARITA RY PECANS OE TUN A RE envelope addre person; or * by posting it to the person's usual place of business or residence in an envelope addressed fo the person; or * by leaving it at or posting it the address of the person's solicitor in an envelope addressed to that solicitor, A copy of this order must be kept at the licensec premises to which it relates. If o person is barred for an indefinite period or a period exceeding 6 months, the Liquor and Gambling Commissioner must days of service receive a copy and details of this order (in accordance with Section 125 of the Liquor Licensing Act, 1997) fi ficensee/responsible person, or the order will cease to have 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 at the licensed premises to which it relates) | certify that a duplicate of this order was served on: Name of person to be barred Feary C1 Posting to the following address Dackie Qacg veline Grae No: street: suburb: postcode: C1 Leaving it at the following address No: street: suburb: postcode: 2416 ees OF sane ES IO nn SIQNEM: ...ecseesves easeeie Si :5ss500s 5505 c1usSA5i:pSOCESEELELETdnsdyithiesttvendvedi iunlivinecietbeenbenbeantnisientiaiisersieenvinmisinbsiaerneriahiimmelinnawian (person effecting the service} EFTA00266670