Form Ap-146-3 - Texas Original Application For Coin-Operated Machine Registration Certificate And Tax Permit(S) Page 5

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Texas Original Application

AP-146-5

(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 3

Legal name (same as Item 2)

15. For each machine at this location (Item 13) requiring a permit, list the serial number/inventory I.D. number, machine make and machine type. For each additional

location, complete a separate Machine Inventory Supplement for Registration Certificate Holder, Form AP-144, or a computer printout of all numbered inventory

may be used. If you use a computer printout, you MUST complete Items 16 and 17.

MACHINE SERIAL

MACHINE MAKE

MACHINE TYPE CODE

NUMBER/INVENTORY

(Use letter codes from Item 16)

I.D. NUMBER

MANUFACTURER

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

16. Enter the number of each type of music, skill or pleasure coin-operated machine that you have in all locations.

– A –

– B –

– C –

– D –

– E –

– F –

PHONOGRAPHS

POOL TABLES

PINBALL GAMES

VIDEO GAMES

DARTS

OTHER

17. Total number of machines in all locations that require tax permits. (Total of Item 16 A - F) .................................................................... _______________________