Coin Operated Amusement Machine Location List
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Coin Operated Amusement Machine Location List Form. This is a Georgia form and can be use in Department Of Revenue Statewide.
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Tags: Coin Operated Amusement Machine Location List, ATT-301, Georgia Statewide, Department Of Revenue
Page ______ of ______
ATT-301 (Rev. 4/12)
Georgia Department of Revenue
ATD-COAM
P.O. Box 105458
Atlanta, Georgia 30348-5458
(404) 417-4900
ATDIV@dor.ga.gov
STATE TAXPAYER ID NUMBER ___________________
MASTER LICENSE NUMBER _____________________
Please type or print legible. All information below must be
complete. Any incomplete information will result in the
rejection of the COAM application. This form is required
for all COAM class A and B Master License Applications
and Renewals.
COIN OPERATED AMUSEMENT MACHINE LOCATION LIST
LOCATION
LEGAL BUSINESS
NAME
LOCATION
TRADE NAME
LOCATION ADDRESS
CITY, ZIP CODE
NUMBER OF NUMBER OF
CLASS B
CLASS A
MACHINES
MACHINES
If additional pages are required, please use a blank copy of this form.
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