LOCATION LICENSE COIN OPERATED AMUSEMENT MACHINE APPLICATION ATT-300LLA (Rev. 4/11) OFFICE USE ONLY Georgia Department of Revenue ATD - COAM LICENSE PERIOD P.O. Box 105458 ___ ___ / ___ ___ /___ ___ ___ ___ ___ ___ / ___ ___ /___ ___ ___ ___ Atlanta, Georgia 30348-5458 (404) 417-4900 ATDIV@dor.ga.gov TOTAL AMOUNT RECEIVED $ ______________________ LOCATION LICENSE NUMBER (PLEASE PRINT OR TYPE) IDENTIFICATION SECTION 1. STATE TAXPAYER IDENTIFIER(STI) NUMBER 1a. MASTER LICENSE NUMBER (if applicable) 2. LEGAL BUSINESS NAME 2a. DBA or TRADE NAME (if applicable) 3. PRIMARY LOCA TION ADDRESS (Number and Street) 3a. EMAIL ADDRESS COUNTY STATE ZIP CODE + 4 PHONE COUNTY 4. CITY STATE ZIP CODE + 4 PHONE ( ) - 5. MAILING ADDRESS (Number and Street) 6. CITY ( ) - MASTER LICENSE AND PAYMENT SECTION 7. Master License Numbers Displayed at location: Total Fees for Location License 8. Number of Class A Machines Per License 8a. Class A - $25 fee for each machine 9. Number of Class B 10a. Class B -$125 Machines Per License fee for each machine $ Total Payments $ Duplicate Original License Fee - $100 (notarized affidavit must be attached) Processing Cost for Location License Temporary Operating License - $ 50.00 Processing Cost Temporary License - $50.00 * TOTAL PAYMENT DUE No REFUND of any of these fees/costs are authorized if owner ceases operation prior to the end of the License period. MAKE CHECK PAYABLE TO THE ”GEORGIA DEPARTMENT OF REVENUE”. GEORGIA LAW STIPULATES THAT TAXES AND FEES/COSTS SHALL BE PAID IN LAWFUL MONEY OF THE U.S. FREE OF EXPENSE TO GEORGIA. SIGNATURE SECTION YES NO The applicant is a United States citizen or legal permanent resident at least eighteen (18) years old. The applicant is a qualified alien or non-immigrant under the Federal Immigrant and Nationality Act, Title 8 U.S.C., at least eighteen (18) years old and is lawfully present in the United States. The applicants alien number issued by the Department of Homeland Security or other federal immigration agency must be provided. Alien Number: Under penalty of law, I declare this application has been completed or throughly examined by me and is true and correct. (Signature) (Title) (Date) (Must be signed by the owner, partner or authorized officer of the corporation. Stamped signature is not acceptable) SEE REVERSE SIDE FOR ADDITIONAL INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com ATT-300LLA (Rev. 4/11) STATE OF GEORGIA DEPARTMENT OF REVENUE INSTRUCTIONS FOR COMPETION OF COIN OPERATED AMUSEMENT MACHINE REGISTRATION APPLICATION (FOR ATT-300 LLA) (TYPE OR PRINT IN INK - DO NOT USE PENCIL) Use this form to apply for a license and decals for coin-operated music or amusement machines (e.g.): pinball machines, console machines, video games, crane machines, claw machines, pusher machines, bowling machines , novelty arcade games, football/table soccer machines, miniature racetrack/foosball or golf machines, target/shooting gallery machines, basketball machines, shuffleboard games, kiddie ride games skeeball machines, air hockey machines, roll down machines, coin-operated pool tables, and every coin-operated machine of any kind which provides music, such as juke boxes. For further information, refer to Georgia Codes 48-17-1 through 48-17-14. This form can be used as a COAM renewal or initial registration application. When used as a renewal application the data is prepopulated in the correct fields on the front of the form. If being used as an initial registration application, form CRF-002 must be completed before licenses and/or decals can be issued. Also please follow instructions in the identification section below to complete this form. All other sections must be completed whether using this form as a renewal or initial registration application. INSTRUCTIONS FOR COMPLETING FORM ATT-300 LLA: A. IDENTIFICATION SECTION Line 1 1a Line 2 2a Line 3 3a Line 4 Line 5 Line 6 -Enter your Georgia State Taxpayer Identifier (STI). If you do not have one, leave blank. You must also complete a CRF-002 if you do not have a Georgia State Taxpayer Identifier (STI). -Enter your Master License Number if you are the holder of the current master license. -Enter your legal business name listed on Form CRF-002. -Enter your DBA name from Form CRF-002 -Enter the physical location address of your business. (A post Office Box or PMB is not an acceptable location address). -Enter your business email address. -Enter your business city, county, state, zip code and also phone number. -Enter your mailing address for your business. -Enter your mailing city, county, state, zip code and also phone number. B. MASTER LICENSE AND PAYMENT SECTION Line 7 -Enter Master License Numbers for each amusement machine at your location. Line 8 -Enter the number of Class A machines per master license. Line 9a -Enter the payment amount (number of Class A machines * $25.00). Line 9 -Enter the number of Class B machines per master license. Line 10a -Enter the payment amount (number of Class B machines *125.00). (If applicable, add columns 8a and 10a into total Payments box.) Enter all other applicable fees/cost. Enter the TOTAL PAYMENT DUE. License payments are not prorated. * NOTICE: In order to continue operating coin-operated music or amusement machines while their application is being processed and the background check is being conducted and prior to the issuance of a Coin Operated Amusement Machine Location License, the applicant may obtain a Temporary License for an additional fee of $50.00. If applicable, please include the additional processing fee of the Temporary License in the proper space and in the Total Payment Due space on the application. Temporary License fees are non-refundable . After the issuance of a Temporary License, in the event a Coin Operated Amusement Machine Location License is not issued; a processing fee of $200.00 will be assessed against the application and will be deducted from the license fee refund. When applying for a duplicate license you must attach an affidavit, showing the reason that you need a duplicate (e.g., lost license, etc.). The registration fee must be made payable to the GEORGIA DEPARTMENT OF REVENUE. Georgia law stipulates that taxes fees shall be paid in lawful money of the U.S. and be free of expense to Georgia. C. SIGNATURE SECTION This application must be signed by the owner, a partner, or an authorized officer of the corporation. D. INSTRUCTION FOR MAILING Mail the original application, with payment attached to the address shown below. Please retain copies for your files. GEORGIA DEPARTMENT OF REVENUE ATD-COAM P. O. BOX 105458 ATLANTA, GA 30348-5458 Please allow 4 to 6 weeks for processing. For further information call (404) 417-4900. IMPORTANT NOTICE: Your permit will not be issued if there are any outstanding liabilities against your account(s). American LegalNet, Inc. www.FormsWorkFlow.com