Application For Mechanical Device License
ADVERTISEMENT
1APPLICATION FOR MECHANICAL DEVICE LICENSE
Ward: _________
Parcel No: _______ - ____ - ________
Zoning District: _________
Location:
Name: ____________________________________________
Telephone: (
) _______________
Address: ____________________________________ City: _______________ Zip Code: __________
Owner:
Name: ____________________________________________
Telephone: (
) _______________
Address: ____________________________________ City: _______________ Zip Code: __________
Vendor:
Name: ____________________________________________
Telephone: (
) _______________
Address: ____________________________________ City: _______________ Zip Code: __________
check one
[
] Corporation
[
] Partnership
[
] Individual
NUMBER OF MACHINES
Type
No. of Machines
Each
Fee
Mechanical/Video Devices
__________
X
$600.00
$ ___________
Juke Box
__________
X
$100.00
$ ___________
Pool Table
__________
X
$100.00
$ ___________
Pool Hall
__________
X
$300.00
$ ___________
Bowling Alley
__________
X
$200.00
$ ___________
Arcade
$15,000.00
$ ___________
TOTAL FEE
$ ___________
CERTIFICATION
I (or we), the undersigned applicant, owner and/or proprietor for the device(s) listed above, hereby acknowledge, subject to the
penalties of PA C.S. §4904 (relating to unsworn falsification to authorities).
I (or we) further acknowledge that none of the mechanical devices listed above is/are designed for the use as a gambling
device; equipped for use as a gambling device; intended to be used for gambling purposes; nor will the listed mechanical devices be
used for gambling purposes. I (or we) understand and acknowledge that the laws of the Commonwealth of Pennsylvania (PA C.S.
§5513) prohibit the use of any video game or machine or any other device for gambling purposes. I (or we) acknowledge that the use of
any of the mechanical devices listed above for gambling purposes can subject me (or us) to criminal prosecution for violation of state
and/or federal laws and can result in the forfeiture of property, monetary fines and/or incarceration.
I (or we) further acknowledge that no statements, guarantees or promises of non-prosecution, either expresses or implied,
have been made by any Borough employee or agent.
______________________________
____________
______________________________
____________
Signature of Vendor
Date
Signature of Owner or Proprietor
Date
BOROUGH APPROVAL
Permit No.___________
Invoice No.___________
Check No.___________
Approved by: _________________________________________________________
Date: ______________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial