Video Gaming License Application

The annual license term runs May 1st through April 30th.
The annual license fee payable to the City for a licensed private business shall be $1,000 for each video gaming establishment and $1,000 for each video gaming terminal. Fees for non-for-profit establishments shall be $250 per establishment and $250 for each video gaming terminal.
Applicant's Corporate Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Business Address*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Business Phone #*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email*field type email
# Terminalsfield type single line
Number of video gaming terminals to be operated (maximum 6)
Input blocked. Maximum character limit of 4000 characters reached.
Previous App?field type radio button
Have you made an application for a similar license for premises other than described in this location
Previous App?NoYes
Previous Infofield type multi line
Provide the date, location of premises, and disposition of the previous application.
License Revoked?field type radio button
Has any license previously issued to you by State, Federal, or local authorities been revoked?
License Revoked?NoYes
Revoked Infofield type multi line

Terminal Operator Information

The local business is not the terminal operator. The terminal operator is the business that you get your machines from.
Name of Operatorfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Address of Operatorfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Phone # of Operatorfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Operator Emailfield type email
Applicant Signature*field type signature
Acknowledgement*field type checkbox
AcknowledgementI understand that checking this box constitutes a legal signature and confirms that I have filled out this form to the best of my ability.
Titlefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Date*field type date