Form Dr-18n - Application For Amusement Machine Certificate - 2016 Page 4
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4DR-18
T
his page may be photocopied to provide additional location information. Front page must always be included.
R. 01/16
Page 2
LOCATION # 1 Sales Tax Certificate Number for the location county:
_________ - _______________________________ - ______
(You must provide an active sales tax number for this county.)
Location Business Name ______________________________________________________________________________________
Physical street address (Do not use PO Box) _____________________________________________________________________
City ______________________________ County ______________________ State ____________________ ZIP ________________
Maximum number of machines to be operated at this location:
Check One:
q New Location ...........................................................Total number of machines
x $30 = $
q Annual Renewal .......................................................Total number of machines
x $30 = $
q Change Amusement Machine Certificate ..................... Additional machines
x $30 = $
LOCATION # 2 Sales Tax Certificate Number for the location county:
_________ - _______________________________ - ______
(You must provide an active sales tax number for this county.)
Location Business Name ______________________________________________________________________________________
Physical street address (Do not use PO Box) _____________________________________________________________________
City ______________________________ County ______________________ State ____________________ ZIP ________________
Maximum number of machines to be operated at this location:
Check One:
q New Location ...........................................................Total number of machines
x $30 = $
q Annual Renewal .......................................................Total number of machines
x $30 = $
q Change Amusement Machine Certificate ..................... Additional machines
x $30 = $
LOCATION # 3 Sales Tax Certificate Number for the location county:
_________ - _______________________________ - ______
(You must provide an active sales tax number for this county.)
Location Business Name ______________________________________________________________________________________
Physical street address (Do not use PO Box) _____________________________________________________________________
City ______________________________ County ______________________ State ____________________ ZIP ________________
Maximum number of machines to be operated at this location:
Check One:
q New Location ...........................................................Total number of machines
x $30 = $
q Annual Renewal .......................................................Total number of machines
x $30 = $
q Change Amusement Machine Certificate ..................... Additional machines
x $30 = $
LOCATION # 4 Sales Tax Certificate Number for the location county:
_________ - _______________________________ - ______
(You must provide an active sales tax number for this county.)
Location Business Name ______________________________________________________________________________________
Physical street address (Do not use PO Box) _____________________________________________________________________
City ______________________________ County ______________________ State ____________________ ZIP ________________
Maximum number of machines to be operated at this location:
Check One:
q New Location ...........................................................Total number of machines
x $30 = $
q Annual Renewal .......................................................Total number of machines
x $30 = $
q Change Amusement Machine Certificate ..................... Additional machines
x $30 = $
Summary of Fee(s) Paid
Total Number of Machines on this Application: __________ X $30 = $ _____________________
(total fee remitted with application)
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Parent category: Financial