Eligible Organization Games Of Chance Application - Pennsylvania Department Of Revenue
Download a blank fillable Eligible Organization Games Of Chance Application - Pennsylvania Department Of Revenue in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Eligible Organization Games Of Chance Application - Pennsylvania Department Of Revenue with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4REV-1752 AS (03-15)
FOR LICENSING AUTHORITY
ELIGIBLE ORGANIZATION
USE ONLY
GAMES OF CHANCE
APPLICATION
Licensing Authority – Enter County
MM/DD/YYYY - Format for all Date fields
Name or Governing Authority Name,
Please Print or Type.
Address and Telephone Number
IMPORTANT: READ INSTRUCTIONS ON PAGE 4 BEFORE COMPLETING APPLICATION
Start
1. Check Appropriate Block:
o
o
o
Initial Application
Annual Application
Change of Data
The licensing authority must be notified of changes to the information included on this application within 15 days of the change.
2. Submit a check, cashier’s check or money order payable to the licensing authority named above for the fee due.
TYPE OF APPLICATION
FEE
EXPLANATION
o
Game of Chance License
$125.00
Required for application.
o
Monthly License
$25.00
Required for application.
➡
o
Replacement License
Issued only if original is defaced, destroyed or lost. Contact the licensing
authority for current fee.
3. Name of Municipality (city, borough, incorporated town or township)
4a. Liquor Identification Number (LID)
5. Indicate Type of Organization (See instructions on Page 4.)
4b. Liquor License Number (if applicable)
o
6.
If incorporated, check here and
attach copy of articles of incorporation.
7. Name of Organization
8. Date Organization was Formed
9. Location of Organization and Licensed Premises
A. Address of Normal Business or Operating Site
Street
County
City
State
ZIP Code
Telephone Number
Email Address
o
B. Mailing Address
Check if same as 9a
Street
County
City
State
ZIP Code
Telephone Number
o
C. Licensed Premises
Check if same as 9a
Street
County
City
State
ZIP Code
Telephone Number
Licensed Premises is (check applicable box)
o
o
o
Owned by organization
Leased by organization
Owned or leased by another licensed eligible organization and
leased to or used by the organization
o
Other (Explain):
THIS FORM MAY BE REPRODUCED
Page 1
RESET FORM
PRINT
NEXT PAGE
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Rev-291 Ex - Nonwithholding Of Pa Income Tax Application - Pennsylvania Department Of Revenue
Financial
Local Government Limited Gaming Impact Fund Application - Colorado Department Of Local Affairs
Legal
Related Categories
Parent category: Financial