Form Att-300b - Coin-Operated Amusement Machine Registration Application
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MASTER LICENSE - CLASS B
COIN OPERATED
AMUSEMENT MACHINE
ATT-300B
(Rev. 4/11)
APPLICATION
OFFICE USE ONLY
Georgia Department of Revenue
TOTAL AMOUNT RECEIVED
ATD-COAM
P.O. Box 105458
$ ______________________
Atlanta, Georgia 30348-5458
LICENSE PERIOD
(404) 417-4900
MASTER LICENSE NUMBER
ATDIV@dor.ga.gov
___ ___ / ___ ___ ___ ___ ___ ___
___ ___ / ___ ___ ___ ___ ___ ___
/
/
(PLEASE PRINT OR TYPE)
IDENTIFICATION SECTION
1. STATE TAXPAYER IDENTIFIER (STI) NUMBER
1a. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)
2. LEGAL BUSINESS NAME
2a. DBA or TRADE NAME (if applicable)
3. PRIMARY LOCATION ADDRESS (number and street)
3a. EMAIL ADDRESS
4. CITY
COUNTY
STATE
ZIP CODE+4
PHONE
(
)
-
5. MAILING ADDRESS (number and street)
6. CITY
COUNTY
STATE
ZIP CODE+4
PHONE
(
)
-
PAYMENT SECTION
Number of
License Fee
7. LICENSE FEES: (Check the appropriate box(es) and return the total amount due with the application.)
Machines
a.
MASTER LICENSE (All Machines) Master License Fee - $5,000.00
b.
PROCESSING FEE FOR INITIAL OR RENEWAL APPLICATION - $50.00
c.
ANNUAL PERMIT STICKER FEE ($125.00 PER MACHINE) (Total machines x $125.00)
d.
PENALTY FEE: Machine in operation without a sticker ($250.00 per machine) (Total machines x $250.00)
REINSTATEMENT FEE ($75.00 per machine) (Total machines x $75.00)
T
e.
f.
DUPLICATE ORIGINAL LICENSE FEE (notarizd affidavit be attached) - $100.00
LATE PENALTY FEE - $125.00
g.
h.
TEMPORARY LICENSE FEE - $50.00 0 **
TOTAL PAYMENT DUE
Note: Sticker must be affixed to machine.
No REFUND of any of these fees/costs are authorized if owner ceases operation prior t
o 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
Alien Number:
the Department of Homeland Security or other federal immigration agency must be provided.
Under penalty of law, I delcare this application has been completed or thoroughly 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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Parent category: Financial