REV-656 AS+ (10-08)
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COUNTY
APPLICATION FOR
LICENSE TO RESELL
LICENSE YEAR
AMUSEMENT TICKETS
DATE
PO BOX 280909
HARRISBURG, PA 17128-0909
Please Print or Type
Applicant Name:
Business Location: (number, street, city or town, county, state). Any change of location must be approved by the County
Treasurer. Only one location change per calendar year is permitted.
INDIVIDUALS, complete the following:
a. Home Address
b. Social Security Number
c. How long have you lived in Pennsylvania?
(The law requires that you live at least one year in Pennsylvania before applying for this license.)
d. Are you a U.S. citizen?
Yes
No
ASSOCIATIONS OR PARTNERSHIPS, complete the following:
a. Home Address:
1)
(NAME)
(STREET)
(CITY)
(COUNTY)
(STATE)
(ZIP CODE)
2)
3)
b. Are all members or partners U.S. citizens?
Yes
No
CORPORATIONS, complete the following:
a. Name and address of principal officers and manager:
President
(NAME)
(STREET)
(CITY)
(COUNTY)
(STATE)
(ZIP CODE)
Vice-President
Secretary
Treasurer
Manager
b. Are all the above U.S. citizens?
Yes
No
c. Are all other officers, directors and stockholders (other than those listed above) U.S. citizens?
Yes
No
d. Are you applying as a Pennsylvania Corporation?
Yes
No
• If yes, give date and place of incorporation
• If no, give date of Certificate of Authority to transact business in Pennsylvania
NOTE: Attach a separate sheet listing the names and addresses of officers, directors and stockholders of the corporation who
are not listed above.
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