Form 410 Maryland Slot Machine License Application

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MARYLAND SLOT MACHINE
FORM
410
LICENSE APPLICATION
124100049
NEW LICENSE
RENEWAL
Office Use Only
SECTION 1 - APPLICANT INFORMATION
Number _____________________
Name of nonprofit organization
Licence Year __________________
Name of county where the physical business is located
Central Registration Number
Phone Number
License Number ______________
Physical business location - street address (P.O. Box NOT acceptable)
Approved ___________________
City
State
Zip Code
Date ________________________
Mailing address - Street Address/P.O. Box (If different from the physical business address above.)
Check Number _______________
City
State
Zip Code
Check Amount $ ______________
Deposit Date _________________
Have you been located in the county for at least 5 years?
Yes
No
Name of Principal Officer
Social Security Number
Mailing address - Street Address/P.O. Box
Federal Employer Identification Number
City
State
Zip Code
Phone number
Fax number
Email address
Name of Alternate Contact
Phone number
Fax number
Email address
The Applicant is:
Under which of the following 501(c) sections of the Internal
Fraternal organization
Revenue Code has the applicant obtained tax-exempt status?
Religious organization
Fraternal organization; IRC § 501(c)(8) or (c)(10)
War Veterans’ organization
War Veterans’ organization; IRC § 501(c)(4) or (c)(19)
Nonprofit organization affiliated with national fraternal
Religious organization; IRC § 501(c)(3)
organization less than 5 years and located in county for at
least 50 years
Other (specify): ________________________
Attach a copy of the IRS § 501(c) tax-exempt determination
Does applicant have tax-exempt status under
letter .
the Internal Revenue Code? . . . . . . . . . . . . . .
Yes
No
The applicant is NOT located in Ocean City
east of South and North Baltimore Avenues . . .
Yes
No
SECTION 2 - SLOT MACHINE INFORMATION
Does applicant own each slot machine for which a license is applied? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Provide the following information for each slot machine (Attach invoice for each slot machine if purchased within the year prior to a
new application)
Make
Model
Serial Number
Year of purchase
1
2
3
4
5
COM/RAD-410
04/12
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