Form 410 Maryland Slot Machine License Application Page 3
Download a blank fillable Form 410 Maryland Slot Machine License Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 410 Maryland Slot Machine License Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4MARYLAND SLOT MACHINE
FORM
410
LICENSE APPLICATION
124100249
SECTION 4 - AFFIDAVIT OF ORGANIZATION
I DECLARE UNDER PENALTIES OF PERJURY THAT THIS APPLICATION HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY
KNOWLEDGE AND BELIEF IS TRUE, CORRECT, AND COMPLETE.
Signature of Principal Officer
Type or Print Name of Principal Officer
Date
SECTION 5 - THIRD PARTY CHECKS
Affidavit
I do solemnly declare and affirm under the penalties of perjury that the contents below are true and correct to the best of my knowledge,
and that I am authorized and empowered to issue a check and make payment for the license/permit fee on behalf of the applicant.
Name of Corporation; Partners of Partnership; or Individual (include Trade Name)
Complete Mailing Address/ Street, P.O. Box
City, State Zip
Signature of Owner, Partner or Corporate Officer
Title
Federal Identification Number and/or Social Security Number
Date
SECTION 6 - THIS SECTION MUST BE COMPLETED BY THE OWNER OF THE PREMISES
Statement of owner of Premises required in connection with Criminal Law Article, 12-304(e) Annotated Code of Maryland (I/we) hereby
certify, that (I am/we are) the owner(s) of property known as ________________________________________________________
named in this application submitted to the Comptroller; that (I/we) assent to the granting of the license applied for, and that (I/we)
hereby authorize the Comptroller, and the Comptroller’s duly authorized personnel and designee, full authority to inspect and search,
without warrant, at all hours, any place of business in which slot machines are authorized to be kept and operated by a licensee.
Affidavit
I do solemnly declare and affirm under the penalties of perjury that the contents of this application are true and correct to the best of
my knowledge, information and belief.
Signature
Type or Print Name
Title
Date
COM/RAD-410
04/12
Page 3 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal