Form Rev-1753 As Application For Small Games Of Chance

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REV-1753 AS (03-16)
OFFICIAL USE ONLY
APPLICATION FOR
SMALL GAMES OF CHANCE
ACCOUNT NUMBER:
DISTRIBUTOR
- D -
LICENSING OF DISTRIBUTORS AND
BUREAU OF BUSINESS TRUST FUND TAXES
MANUFACTURER - M -
REGISTRATION OF MANUFACTURERS
PO BOX 280906
HARRISBURG, PA 17128-0906
SECTION I.
APPLICATION INFORMATION
START
Check type of application:
Initial Application
Annual Application
Change of Data (attach appropriate statements)
Type of Application
Fee
Explanation
Distributor License
$2,000
Required for initial and every annual application.
Manufacturer Registration Certificate
$2,000
Required for initial and every annual application.
Replacement Certificate or License
$100
Issued only if original is defaced, destroyed or lost.
Every application (initial & annual) must include a $10
Background Investigation for (______ Individuals X $10) =
$________
Background Investigation fee for each individual listed on
Schedule A (manufacturer applicants only) or Schedules A
and B (distributor applicants only).
Total Amount Remitted:
$________
If the department denies an application, a $100 application processing fee will be retained by the department. The remaining
fee will be returned to the applicant. No part of the registration or license fee shall be subject to proration. No investigation fee
will be refunded.
SECTION II.
DISTRIBUTOR’S LICENSE INFORMATION
If applying for a distributor’s license number, complete the following information.
Legal Business Name
Telephone Number
Business Address (P.O. Box is not acceptable)
City
State
ZIP Code
Mailing Address (if different than business address)
City
State
ZIP Code
Revenue ID
PA Withholding Account Number
Unemployment Compensation Account Number
FEIN
Sales and Use Tax License Number
SECTION III.
MANUFACTURER’S REGISTRATION INFORMATION
If applying for a manufacturer’s registration number, complete the following information.
Legal Business Name
Telephone Number
Business Address (P.O. Box is not acceptable)
City
State
ZIP Code
Mailing Address (if different than business address)
City
State
ZIP Code
Revenue ID
PA Withholding Account Number
Unemployment Compensation Account Number
FEIN
Sales and Use Tax License Number
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