Form 410 Maryland Slot Machine License Application Page 2
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4MARYLAND SLOT MACHINE
FORM
410
LICENSE APPLICATION
124100149
Is each slot machine equipped with a tamper proof meter or counter that accurately records gross receipts? . . . . . . .
Yes
No
a. List location of principal meeting hall ________________________________________________________________________
(Attach a copy of deed or lease stating that the principal meeting hall is owned or under control of the applicant, including the
rules of operation) - Owner of Premise Affidavit?
b. Are all slot machines located and operated at this principal meeting hall? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
(If no, you are not eligible for the slot machine license(s))
c. If location is shared with, or leased to, another organization, explain how the slot machines prohibited from use when the other
organization is using and operating at the location. _____________________________________________________________
_____________________________________________________________________________________________________
(Attach a copy of any lease or other documents)
SECTION 3 - LICENSING INFORMATION
1.
Does the applicant agree to submit a copy of the invoice to the Comptroller for each new slot machine
purchased? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
2.
Does the applicant agree to keep each slot machine equipped with a tamper proof meter or counter to accurately
record gross receipts? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
3.
a. Does the applicant agree to distribute at least one-half (50%) of its net after payout proceeds from slot
machines for the benefit of a charity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
b. Does the applicant agree to use the remainder of its net after payout proceeds from slot machines (after at least
a 50% distribution to a charity) to further the purposes of its organization? . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
4.
Does the applicant agree to submit an annual report on or before August 1 to the Comptroller stating the income
of each slot machine and the disposition of the income from each slot machine? . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
5.
a. Does the applicant agree to keep an accurate record of the gross proceeds and payoffs of each slot machine? . .
Yes
No
b. Does the applicant agree to make these records available for inspection by the Comptroller? . . . . . . . . . . . . .
Yes
No
c. Does the applicant agree to maintain these records for at least 4 years? . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
6.
Does the applicant agree to place a license (decal) on each slot machine? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
7.
Does the applicant agree to take “weekly” readings of each slot machine and have this information available in a
log for inspection on request by the Comptroller? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
8.
Does the applicant agree to conform to all laws, rules, and regulations of the State of Maryland and any local
jurisdiction relating to the slot machine operation granted under this license? . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
9.
Does the applicant authorize the Comptroller of Maryland and the Comptroller’s duly authorized personnel or
designee to inspect and search without a warrant any slot machine used under this license at any and all hours
consistent with the laws of the State of Maryland? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
10. Has the applicant’s principal officer ever been convicted of perjury? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
11. Does the applicant agree to notify the Comptroller within 24 hours prior to any repair to, or installation of, a slot .
machine? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
12. Does the applicant agree to immediately notify the Comptroller when the principal officer of the organization has
changed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
13. Does the applicant agree to notify the Comptroller prior to the organization’s principal meeting hall changing
location? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
COM/RAD-410
04/12
Page 2 of 4
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