Texas Original Application
AP-146-4
(Rev.8-11/15)
for Coin-Operated Machine
Registration Certificate and Tax Permit(s)
––– Attach additional sheets, if necessary. –––
• Please read instructions.
• Type or print.
• Do NOT write in shaded areas.
Page 2
Legal name (same as Item 2)
14. Check the applicable boxes and complete the information below:
Position (Check all applicable boxes.)
Percentage of ownership or
corporate
%
Sole owner
Partner
Director
Officer
Corporate stockholder
Record keeper
stock held
Name (last, first, middle initial)
Social Security number
Driver license number and state
Home address (street)
City
State
ZIP code
Daytime phone (area code and number)
Date of birth (mmddyyyy)
(
)
-
Position (Check all applicable boxes.)
Percentage of ownership or
corporate
%
Partner
Director
Officer
Corporate stockholder
Record keeper
stock held
Name (last, first, middle initial)
Social Security number
Driver license number and state
Home address (street)
City
State
ZIP code
Daytime phone (area code and number)
Date of birth (mmddyyyy)
(
)
-
Position (Check all applicable boxes.)
Percentage of ownership or
corporate
%
Partner
Director
Officer
Corporate stockholder
Record keeper
stock held
Name (last, first, middle initial)
Social Security number
Driver license number and state
Home address (street)
City
State
ZIP code
Daytime phone (area code and number)
Date of birth (mmddyyyy)
(
)
-
Position (Check all applicable boxes.)
Percentage of ownership or
corporate
%
Partner
Director
Officer
Corporate stockholder
Record keeper
stock held
Name (last, first, middle initial)
Social Security number
Driver license number and state
Home address (street)
City
State
ZIP code
Daytime phone (area code and number)
Date of birth (mmddyyyy)
(
)
-
Position (Check all applicable boxes.)
Percentage of ownership or
corporate
%
Partner
Director
Officer
Corporate stockholder
Record keeper
stock held
Name (last, first, middle initial)
Social Security number
Driver license number and state
Home address (street)
City
State
ZIP code
Daytime phone (area code and number)
Date of birth (mmddyyyy)
(
)
-
Position (Check all applicable boxes.)
Percentage of ownership or
corporate
%
Partner
Director
Officer
Corporate stockholder
Record keeper
stock held
Name (last, first, middle initial)
Social Security number
Driver license number and state
Home address (street)
City
State
ZIP code
Daytime phone (area code and number)
Date of birth (mmddyyyy)
(
)
-
1
2
3
4
5
6
Form Ap-147-3 - Texas Original Application For Coin-operated Machine General Business License, Import License And/or Repair License And Tax Permit(s)
Financial
