Form Rev-1753 - Application For Small Games Of Chance
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4REV-1753 AS + (2-06)
APPLICATION FOR
ACCOUNT NUMBER:
SMALL GAMES OF CHANCE
COMMONWEALTH OF PENNSYLVANIA
DISTRIBUTOR
- D-
DEPARTMENT OF REVENUE
LICENSING OF DISTRIBUTORS AND
BUREAU OF BUSINESS TRUST FUND TAXES
MANUFACTURER
- M -
PO BOX 280906
REGISTRATION OF MANUFACTURERS
HARRISBURG, PA 17128-0906
Please Print or Type
1. CHECK THE APPROPRIATE BLOCK(S)
Initial A p p l i c a t i o n
Annual A p p l i c a t i o n
Change of Data (Attach appropriate statements)
TYPE OF A P P L I C ATION
F E E
E X P L A NAT I O N
Distributor License . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 1 , 0 0 0
Required for initial and every annual application.
Manufacturer Registration Certificate . . . . . . . . . . . . . . . . . . . . . . . . .$ 2 , 0 0 0
Required for initial and every annual application.
Replacement Certificate or License . . . . . . . . . . . . . . . . . . . . . . . . . .$ 100
Issued only if original is defaced, destroyed or lost.
Background Investigation for ( _ _ _ _ _ _ _ _ _ _ _ Individuals X $10) =
$
Every application (original & a n n u a l) must include a
$10 Background Investigation fee for each individual
listed on Schedule A. Indicate number of individuals
listed and total background fee due.
Total Amount Remitted:
$
If the Department denies an application, a $100 application processing fee will be retained by the Department. The remaining fee will be
returned to applicant. No part of the registration or license fee shall be subject to proration. No investigation fee will be refunded.
2. IF APPLYING FOR A DISTRIBUTOR’S LICENSE NUMBER, COMPLETE THE FOLLOWING:
Legal Business Name
Telephone Number
(
)
Business Address (Post Office Box Not Acceptable)
Street
City/Town
County
State
Zip Code
Mailing Address (If Different than Business Address)
Street
City/Town
County
State
Zip Code
Pennsylvania Tax Identification Numbers (See Instructions)
Corporation Tax File (Box) Number
PA Withholding Account Number
Unemployment Compensation Account Number
-
-
-
Federal Employer Identification Number
Sales and Use Tax License Number
-
3. IF APPLYING FOR A MANUFACTURER’S REGISTRATION NUMBER, COMPLETE THE FOLLOWING:
Legal Business Name
Telephone Number
(
)
Business Address (Post Office Box Not Acceptable)
Street
City/Town
County
State
Zip Code
Mailing Address (If Different than Business Address)
Street
City/Town
County
State
Zip Code
Pennsylvania Tax Identification Numbers (See Instructions)
Corporation Tax File (Box) Number
PA Withholding Account Number
Unemployment Compensation Account Number
-
-
-
Federal Employer Identification Number
Sales and Use Tax License Number
-
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Parent category: Financial