MASTER LICENSE - CLASS A COIN OPERATED AMUSEMENT MACHINE APPLICATION ATT-300A (Rev. 3/12) Georgia Department of Revenue ATD-COAM P.O. Box 105458 Atlanta, Georgia 30348-5458 (404) 417-4900 ATDIV@dor.ga.gov OFFICE USE ONLY TOTAL AMOUNT RECEIVED $ ______________________ LICENSE PERIOD MASTER LICENSE NUMBER ___ ___ / ___ ___ / ___ ___ ___ ___ ___ ___ / ___ ___ / ___ ___ ___ ___ (PLEASE PRINT OR TYPE) IDENTIFICATION SECTION 1. STATE TAXPAYER IDENTIFIER (STI) NUMBER 1a. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) 2. LEGAL BUSINESS NAME 2a. DBA or TRADE NAME (if applicable) 3. PRIMARY LOCATION ADDRESS (number and street) 3a. EMAIL ADDRESS 4. CITY COUNTY STATE ZIP CODE+4 PHONE ( ) - 5. MAILING ADDRESS (number and street) 6. CITY COUNTY STATE ZIP CODE+4 PHONE ( ) - PAYMENT SECTION 7. LICENSE FEES: (Check the appropriate box(es) and return the total amount due with the application.) a. MASTER LICENSE Machines: (1-5) FEE - $500.00 (6-60) FEE - $2,000.00 Number of Machines License Fee (61 or more) FEE - $ 3,500.00 b. PROCESSING FEE FOR INITIAL OR RENEWAL APPLICATION - $50.00 c. MASTER LICENSE UPGRADE - Put full amount in 7a and existing license credit amount in 7c (*see back) d. ANNUAL PERMIT STICKER FEE ($25.00 per machine) (Total machines x $25.00) e. PENALTY FEE: Machine in operation without a sticker ($50.00 per machine) (Total machines x $50.00) f. REINSTATEMENT FEE - ($75.00 per machine) (Total machines x $75.00) g. DUPLICATE ORIGINAL LICENSE FEE (notarized affidavit must be attached) $100.00 h. LATE PENALTY FEE -$125.00 TOTAL PAYMENT DUE Note: Sticker must be affixed to the machine. No REFUND of any of these fees/costs are authorized if owner ceases operation prior to the 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 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 Alien Number: the Department of Homeland Security or other federal immigration agency must be provided. Under penalty of law, I declare this application has been completed or thoroughly examined by me and is true and correct. (Signature) (Title) (Must be signed by the owner, partner or authorized officer of the corporation. Stamped signature is not acceptable.) (Date) SEE REVERSE SIDE FOR ADDITIONAL INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com NO ATT-300A (Rev. 3/12) STATE OF GEORGIA DEPARTMENT OF REVENUE INSTRUCTIONS FOR THE COMPLETION OF COIN-OPERATED AMUSEMENT MACHINE REGISTRATION APPLICATION (FORM ATT-300 A/B) 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 A/B: A. IDENTIFICATION SECTION Line 1- Enter your Georgia State Taxpayer Identifier (STI). (If you do not have one, leave blank) 1a - Enter your Federal Employer Identification Number (FEIN), if applicable. Line 2 - Enter your legal business name listed on Form CRF-002. 2a - Enter your DBA name from Form CRF-002. Line 3 - Enter the physical location address of your business. (A Post Office Box or PMB is not an acceptable location address). 3a - Enter your business email address. Line 4 - Enter your business city, county, state, zip code and phone number. Line 5 - Enter the mailing street address. Line 6 - Enter your mailing city, county, state, zip and phone number (if applicable). B. PAYMENT SECTION Line 7 - Enter the number of machines and all applicable fees and calculate totals. - Enter all other applicable fees (a - h) for Master License A or all other application fees (a-g) for Master License B. - Enter the TOTAL PAYMENT DUE. *NOTE: Master License A upgrade calculation example: Enter master license fee on line 7a. $2,000.00 Enter existing license fee credit on line 7c. -500.00 $1,500.00 Enter TOTAL PAYMENT DUE License payments are not prorated. Failure to timely apply for a Master License will result in the imposition of a $125.00 penalty. Failure to order and affix decals for Class A machines will result in the imposition of a $50.00 per machine penalty and a $250.00 per machine penalty for Class B. Any violation of this law can result in suspension or revocation of your license, seizure of equipment, and debarment for repeat offenders. Equipment can be sold at public auction after 30 days advertisement. The Revenue Commissioner will charge a fee of $75.00 per machine for the release of any machine that has been seized and sealed. No one is authorized to remove the seals after they are in place without written authorizations from the Revenue Commissioner or his authorized agents after payment of penalties. * NOTICE: Master License Processing Fee - The application processing fees is non-refundable. In the event a Master License is not issued; an additional processing fee of $200.00 will be assessed against the application and will be deducted from the license fee refund. ** 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 Master 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 Master License is not issued: a processing fee of $200.000 in addition to the application processing fee, will be assessed against the Temporary License 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 and 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 POST OFFICE BOX 105458 ATLANTA, GEORGIA 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