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2. Business Name *
4. Applicant's Name and Role/Title within the Business*
5. Email Address*
7. Business Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Tax ID#*
16. Business *

    1. Game Room
    2. Indoor Amusement
17. How many redemption machines (max allowed -5)*
    -- Select One --12345
18. How many video games and automated pool tables*
20. Signature *
22. Submit a list of the games with serial numbers.
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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field