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