BUSINESS NAME*

ADDRESS (WHERE DEVICE IS LOCATED)*

BLACK JACK, MO 63033

APPLICANT NAME AND TITLE*

CONTACT NUMBER*

PLACE OF BIRTH*

AGE*

MAILING ADDRESS IF DIFFERENT THAN BUSINESS ADDRESS

EMAIL ADDRESS*

IN COMPLIANCE WITH SECTION 2 OF ORDINANCE NO. 1145 OF THE CITY OF BLACK JACK, MISSOURI, APPLICATION IS HEREBY MADE FOR A CITY OF BLACK JACK 2021/2022 AMUSEMENT DEVICE LICENSE, FOR MACHINE(S) LOCATED AT THE ABOVE PLACE OF BUSINESS

DESCRIPION OF AMUSEMENT DEVICE: ANNUAL FEE IS $30.00 PER DEVICE

NAME*

MANUFACTURER*

SERIAL NUMBER*

NAME

MANUFACTURER

SERIAL NUMBER

NAME

MANUFACTURER

SERIAL NUMBER

NAME

MANUFACTURER

SERIAL NUMBER

NAME

MANUFACTURER

SERIAL NUMBER

NAME

MANUFACTURER

SERIAL NUMBER

EACH LICENSE SHALL EXPIRE ONE (1) YEAR FROM THE DATE OF ISSUANCE. LICENSES MUST BE FIRMLY AFFIXED TO MACHINE PRIOR TO INSTALLATION/OPERATION AND ARE NOT TRANSFERABLE. AMUSEMENT DEVICES WHICH ARE NOT PROPERLY LICENSED ACCORDING TO ORDINANCE NO. 1145 OF THE CITY OF BLACK JACK SHALL CONSTITUTE A VIOLATION.

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FOR OFFICE USE ONLY

OCCUPANCY ____________________

AMUSEMENT NO. _________________

EFFECTIVE _________________

EXPIRE _________________

INSPECTION BY _______________________________

INSPECTION DATE ________________________

PASSED YES ____________ NO ____________

COMMENTS_______________________________________________________________