Part B - Vending machine registration certificates (continued)
A
B
C
Business name
Physical address where vending machine is located
Serial number of each
(report each machine separately in column C)
vending machine
Number of vending machine registration certificates from previous page (if last page, include totals from
additional copies, if attached). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total number of vending machine registration certificates required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter this total on page 1, line 2, column A, as applicable.
72000406150094
DTF-719-C-MN (6/15) (back)