Form Dr-18 - Application For Amusement Machine Certificate Page 4
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4DR-18
T
his page may be photocopied to provide additional location information. Front page must always be included.
R. 03/06
Page 4
Sales Tax
–
–
Number:
Name of Operator: ___________________________________________________
Amusement Machine Location Information
Machines are operated at the following location(s) (Note: A separate certificate will be issued for each individual location)
7.
LOCATION #1
Business name ___________________________________________________________________________________________
Physical address (Do not use PO Box) ______________________________________________________________________________________________
City____________________________________________County ________________________State _________________________ ZIP________________
Maximum number of machines
to be operated at this location:
Check One:
x $30 = $
❏
New location ........................................................................... Total number of machines
❏
Update of Amusement Certificate Number
x $30 = $
–
–
.......Additional machines
8.
LOCATION #2
Business name ___________________________________________________________________________________________
Physical address (Do not use PO Box) _____________________________________________________________________________________________
City____________________________________________County ________________________State _________________________ ZIP________________
Maximum number of machines
to be operated at this location:
Check One:
x $30 = $
❏
New location ............................................................................Total number of machines
❏
Update of Amusement Certificate Number
x $30 = $
–
–
...... Additional machines
9.
LOCATION #3
Business name ___________________________________________________________________________________________
Physical address (Do not use PO Box) _____________________________________________________________________________________________
City____________________________________________County ________________________State _________________________ ZIP________________
Maximum number of machines
to be operated at this location:
Check One:
x $30 = $
❏
New location ............................................................................Total number of machines
❏
Update of Amusement Certificate Number
x $30 = $
–
–
.......Additional machines
10.
Summary of Fee(s) Paid
This application and the required $30 per machine fee
Total Number of Machines
may be delivered to the nearest Florida Department of
on this Application:
Revenue service center or mailed to:
x $30
Amusement Machine Certificate Room - 1-5600
Florida Department of Revenue
$
5050 W Tennessee St
Tallahassee FL 32399-0156
(total fee remitted with application)
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