Form Rv-F1306201 - Application For Registration For Coin-Operated Amusement Machine Tax
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1TENNESSEE DEPARTMENT OF REVENUE
APPLICATION FOR REGISTRATION
COIN-OPERATED AMUSEMENT MACHINE TAX
COMPLETION OF THIS APPLICATION WILL REGISTER YOUR BUSINESS FOR THE COIN OPERATED AMUSEMENT
MACHINE TAX.
2. LEVEL OF LICENSE REQUIRED
1. REASON FOR APPLICATION
New Business/Registration
Annual Renewal
Level 1 (50 or Fewer Machines)
Change of Business Location
Six Month License
Level 2 (51 to 199 Machines)
Purchase of Existing Business
Change in License Level
Level 3 (200 or More Machines)
3. DATE BUSINESS BEGAN IN TENNESSEE AT THE CURRENT LOCATION:
4. BUSINESS NAME AND EXACT LOCATION
5. BUSINESS MAILING ADDRESS
Name:
Name:
Street:
Street:
City, State, Zip:
City, State, Zip:
6. BUSINESS TELEPHONE NUMBER: (
)
(
)
Fax #
7. TYPE OF OWNERSHIP:
Limited Partnership
Corporation
Proprietorship
Husband/Wife Ownership
Limited Liability Company
S Corporation
Partnership
Professional Limited Liability Company
Professional Corporation
Other
Name of Corporation
Sec. of State #
8. CURRENT OR PRIOR TAX NUMBERS (Sales Tax etc.) FEIN:
ACCT. NO.
9. IDENTIFY OWNERS, OFFICERS, PARTNERS. DO NOT USE POST OFFICE BOX ADDRESSES. (ATTACH
ADDITIONAL NAMES AND SOCIAL SECURITY NUMBERS ON SEPARATE SHEET.)
(1) Name:
Home Phone:
SSN:
Street:
City:
Home Address:
State:
Zip Code:
(2) Name:
Home Phone:
SSN:
Street:
City:
Home Address:
State:
Zip Code:
(3) Name:
Home Phone:
SSN:
Street:
City:
Home Address:
State:
Zip Code:
10.
IF YOU ARE AN OUT-OF-STATE BUSINESS THAT WILL BE DOING BUSINESS IN TENNESSEE, PLEASE ANSWER THE
FOLLOWING QUESTION. DO YOU HAVE A LOCATION OR OFFICE IN TENNESSEE?
YES
NO
IF YES IDENTIFY THE LOCATION:
11. The statements made on this application are true
DEPARTMENTAL USE ONLY
to the best of my knowledge and belief. (This applica-
tion must be signed by the individual owner, a partner,
or an officer of the corporation listed in Item 9.
Sign
Here:
(Owner, Partner, or Officer (Do Not Use Stamp)
RV-F1306201
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