Form Att-300lla - Location License Coin Operated Amusement Machine Application
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LOCATION LICENSE
COIN OPERATED
AMUSEMENT MACHINE
ATT-300LLA
(Rev. 4/11)
APPLICATION
OFFICE USE ONLY
Georgia Department of Revenue
TOTAL AMOUNT RECEIVED
ATD - COAM
LICENSE PERIOD
$ ______________________
P.O. Box 105458
___ ___ / ___ ___ ___ ___ ___ ___
___ ___ / ___ ___ ___ ___ ___ ___
/
/
Atlanta, Georgia 30348-5458
LOCATION LICENSE NUMBER
(404) 417-4900
ATDIV@dor.ga.gov
(PLEASE PRINT OR TYPE)
IDENTIFICATION SECTION
1. STATE TAXPAYER IDENTIFIER(STI) NUMBER
1a. MASTER LICENSE NUMBER (if applicable)
2a. DBA or TRADE NAME (if applicable)
2. LEGAL BUSINESS NAME
3. PRIMARY LOCA TION ADDRESS (Number and Street)
3a. EMAIL ADDRESS
A
COUNTY
ST
TE
ZIP CODE + 4
PHONE
4. CITY
(
)
-
5. MAILING ADDRESS (Number and Street)
6. CITY
COUNTY
STATE
ZIP CODE + 4
PHONE
(
)
-
MASTER LICENSE AND PAYMENT SECTION
7.
8.
8a.
Master License Numbers Displayed at location:
Number of Class A
Class A - $25
9.
Number of Class B
10a.
Class B -$125
Total
Machines Per License
fee for each machine
fee for each machine
Payments
Machines Per License
$
$
Total Fees for Location License
Duplicate Original License Fee - $100 (notarized affidavit must be attached)
Processing Cost for Location License
$ 50.00
Temporary Operating License -
Processing Cost Temporary License - $50.00 *
TOTAL PAYMENT DUE
No REFUND of any of these fees/costs are authorized if owner ceases operation prior to the end of the License period.
MAKE CHECK PAYABLE TO THE ”GEORGIA DEPARTMENT OF REVENUE”. GEORGIA LAW STIPULATES THAT TAXES AND FEES/COSTS
SHALL BE PAID IN LAWFUL MONEY OF THE U.S. FREE OF EXPENSE TO GEORGIA.
SIGNATURE SECTION
YES
NO
The applicant is a United States citizen or legal permanent resident at least eighteen (18) years old.
The applicant is a qualified alien or non-immigrant under the Federal Immigrant and Nationality Act, Title 8 U.S.C.,
at least eighteen (18) years old and is lawfully present in the United States. The applicants alien number issued by
the Department of Homeland Security or other federal immigration agency must be provided.
Alien Number:
Under penalty of law, I declare this application has been completed or throughly examined by me and is true and correct.
(Signature)
(Title)
(Date)
(Must be signed by the owner, partner or authorized officer of the corporation. Stamped signature is not acceptable)
SEE REVERSE SIDE FOR ADDITIONAL INFORMATION
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