Form Rev-915 - Pennsylvania Small Games Of Chance Game Approval Form
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1BUREAU OF BUSINESS TRUST FUND TAXES
COMMONWEALTH OF PENNSYLVANIA
MISCELLANEOUS TAX DIVISION
PENNSYLVANIA
SMALL GAMES OF CHANCE
DEPARTMENT OF REVENUE
DEPARTMENT OF
PO BOX 280906
evenue
HARRISBURG, PA 17128-0906
REV-915 (01-05)
PENNSYLVANIA SMALL GAMES OF CHANCE
GAME APPROVAL FORM
MANUFACTURER INFORMATION
1. NAME OF MANUFACTURER:
2. LICENSE #:
3. CONTACT PERSON:
PHONE #:
FAX#:
4. ADDRESS (CONTACT PERSON):
THE FOLLOWING INFORMATION IS NEEDED TO SUBMIT A GAME FOR APPROVAL:
GAME INFORMATION
NAME OF GAME:
FORM/BOARD NUMBER(S):
DESCRIPTION OF THE GAME
AND RULES FOR PLAY:
GAME PRIZE STRUCTURE,
PRIZES AND THEIR VALUE:
NUMBER OF CHANCES
AND COST PER CHANCE:
PAY OUT %:
USE 8 1/2 X 11 SHEET(S) OF PAPER TO PROVIDE ADDITIONAL INFORMATION
ATTACH A PICTURE OR ILLUSTRATION OF THE GAME AND ITS COMPONENT PIECES
NOTE: ALL INFORMATION MUST BE COMPLETED OR REQUEST WILL BE DENIED
THE SIGNATURE AND DATE BELOW CERTIFIES ALL INFORMATION SUBMITTED HEREIN IS TRUE AND CORRECT.
SIGNATURE:
DATE:
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