Form Rev-1753 As Application For Small Games Of Chance Page 3
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4REV-1753 AS (03-16)
SMALL GAMES OF CHANCE SCHEDULES
Please specify which type of applicant you are:
Distributor
Manufacturer
Legal Business Name
SCHEDULE A
List the following data for all owners, partners, officers, or directors. If incorporated, list data for all officers, directors and shareholders controlling 10 percent
or more of outstanding stock. If organized as a partnership, list data for all partners. For all entities, list data for any other responsible person.
Name
Title/Relationship
SSN
Street Address
City
State
ZIP Code
Date of Birth
Email Address
Telephone Number
Name
Title/Relationship
SSN
Street Address
City
State
ZIP Code
Date of Birth
Email Address
Telephone Number
Name
Title/Relationship
SSN
Street Address
City
State
ZIP Code
Date of Birth
Email Address
Telephone Number
SCHEDULE B
List all individuals, including owners, partners, officers, directors and sales personnel responsible for taking orders and making sales of small games of chance
merchandise. If an individual resides in Pennsylvania, check whether commissioned or salaried.
Commissioned
Name
Title
Telephone Number
Salaried
Street Address
City
State
ZIP Code
Commissioned
Name
Title
Telephone Number
Salaried
Street Address
City
State
ZIP Code
Commissioned
Name
Title
Telephone Number
Salaried
Street Address
City
State
ZIP Code
SCHEDULE C
To be completed by distributors only. List all manufacturers with whom distributor does business regarding small games of chance.
Name
Title
Telephone Number
Manufacturer’s Certificate Number
Street Address
City
State
ZIP Code
Name
Title
Telephone Number
Manufacturer’s Certificate Number
Street Address
City
State
ZIP Code
Name
Title
Telephone Number
Manufacturer’s Certificate Number
Street Address
City
State
ZIP Code
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