Application Form For Amusement Games License N.j.s.a. 5:8-100 Et Seq - New Jersey Office Of The Attorney General
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3New Jersey Office of the Attorney General
Division of Consumer Affairs
Legalized Games of Chance Control Commission
124 Halsey Street, P.O. Box 46000
Newark, N.J. 07101
(973) 273-8000
Application for Amusement Games License
N.J.S.A. 5:8-100 et seq.
This application must be filed in duplicate. Both copies must be filed with the municipal issuing authority with the full
municipal fee and a certified check or money order, payable to the Legalized Games of Chance Control Commission,
in the amount of $250.00 per state license, unless the license is for a game to be conducted at an Agricultural Fair, in
which case the fee is $50.00 per license. Please note that arcades must submit an additional fee of $10.00 per player
position for each position over the original 50 positions, along with a complete list of all redemption machines. The
amended license fee is $25.00.
Please print clearly.
Section #1 License Identification
Municipality: ______________________________ Municipal License Number __________________________
Date Filed: ________________________________ Municipal License Fees $ __________________________
State License Fees $ __________________________
Section #2 Identification of Applicant
Name of applicant: _____________________________________________________________________________
First name Middle name Last name
Mailing address: _______________________________________________________________________________
Street address City
State ZIP code County
Business telephone number:_____________________________
(Include area code)
Sole Proprietorship Partnership Corporation
Other (explain): ____________________________________________________________________________
If the applicant is an individual, provide the information requested below. If the applicant is a partnership, provide the
information required in this section for each partner. If the applicant, or a partner in the applicant, is a corporation, provide
the information required by this section for each officer, director or stockholder of the applicant corporation and for each
officer, director or stockholder of any corporation that holds five percent (5%) or more of the capital stock of the applicant
corporation and indicate each person's title. Use additional sheets of paper if necessary.
Name and Title: ____________________________________________________ Date of Birth: ________________
Residence Address: ___________________________________ Business telephone number:___________________
(Give exact street address) (Include area code)
Name and Title: ____________________________________________________ Date of Birth: ________________
Residence Address: ___________________________________ Business telephone number:___________________
(Give exact street address) (Include area code)
(Revised 5/6/16)
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