Form - Ar-1r-Amu - Amusement Registration Supplement

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ARKANSAS DEPARTMENT OF FINANCE AND ADMINISTRATION
Amusement Registration Supplement Form - AR-1R-AMU
SECTION A: OWNERSHIP INFORMATION
Legal Name (Enter full legal name of business):
OR
Federal Identification Number (FEIN):
-
Social Security Number (SSN):
-
-
SECTION B: LICENSE TYPE AND DECAL REQUEST
License Type (check the appropriate box)
Rate
Amount Due
Distributor only
$25.00
Distributor Salesman
Number of Licenses:
$5.00
Operator with 1 - 3 machines
$500.00
Operator with 4 or more machines
$1,000.00
Special Event Operator with 1 - 3 machines
Number of Months*:
$75.00
Special Event Operator with 4 or more machines
Number of Months*:
$150.00
Decal Request
Rate
Amount Due
Operator: purchased before Jan 1
Decal Qty Requested:
$5.00
Operator: purchased on or after Jan 1
Decal Qty Requested:
$2.50
Special Event Operator
Decal Qty Requested:
$5.00
Total Amount Due:
*Special Event permits are issued in 30 day increments and cannot exceed 3 per calendar year.
SECTION C: DISTRIBUTOR SALESMEN DETAILS
Salesman's Name
Address
City
State
Zip
SECTION D: BOND INFORMATION**
Bonding Company
Address
City
State
Zip
Bond#
Bond Amount
**IMPORTANT: $6,000.00 Operator bond or $1,000.00 Distributor bond must be attached in order to process this amusement application.
No bond required for Special Event.
(Print Name)
(Signature of Requestor)
Date
Page 1 of 2
Amusement Registration Supplement Form - AR-1R-AMU (R 07/22/13)

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