Form Dr-18 - Application For Amusement Machine Certificate Page 2
ADVERTISEMENT
1
2DR-18
T
his page may be photocopied to provide additional location information. Front page must always be included.
R. 02/00
Page 4
Name of Operator: __________________________ Sales Tax Number: _________ - _______ - _________________ - ________
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 P.O. Box): _____________________________________________________________________
City _____________________________ County ___________________ State ________ Zip _____________ - __________
Operator’s Sales Tax Number for this Location: ______________ - ____________ - _____________ - ____________
Maximum Number of Machines to be Operated at this Location: _______________
Check One:
New Location; Total Number of Machines _______________________ x $30 = $ ___________________________
Update of Amusement Certificate # ____________________________ Additional Machines _______ x $30 = $ ________
8.
Location #2 Business Name:
Physical Address (Do not use P.O. Box): _____________________________________________________________________
City _____________________________ County ___________________ State ________ Zip _____________ - __________
Operator’s Sales Tax Number for this Location: ______________ - ____________ - _____________ - ____________
Maximum Number of Machines to be Operated at this Location: _______________
Check One:
New Location; Total Number of Machines _______________________ x $30 = $ ___________________________
Update of Amusement Certificate # ____________________________ Additional Machines _______ x $30 = $ ________
9.
Location #3 Business Name: _______________________________________________________________________________
Physical Address (Do not use P.O. Box): _____________________________________________________________________
City _____________________________ County ___________________ State ________ Zip _____________ - __________
Operator’s Sales Tax Number for this Location: ______________ - ____________ - _____________ - ____________
Maximum Number of Machines to be Operated at this Location: _______________
Check One:
New Location; Total Number of Machines _______________________ x $30 = $ ___________________________
Update of Amusement Certificate # ____________________________ Additional Machines _______ x $30 = $ ________
10.
Location #4 Business Name: _______________________________________________________________________________
Physical Address (Do not use P.O. Box): _____________________________________________________________________
City _____________________________ County ___________________ State ________ Zip _____________ - __________
Operator’s Sales Tax Number for this Location: ______________ - ____________ - _____________ - ____________
Maximum Number of Machines to be Operated at this Location: _______________
Check One:
New Location; Total Number of Machines _______________________ x $30 = $ ___________________________
Update of Amusement Certificate # ____________________________ Additional Machines _______ x $30 = $ ________
11. Summary of Fee(s) Paid
Total Number of Machines on this Application: _______________ x $30 = $ ______________
(total fee remitted with application)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial