Amusement Device & Jukebox Application

2. City Clerk's Office
   (712) 328-4616

   (712) 328-4616

4. First Name

5. Last Name

7. Address

9. City

10. State

11. Zip

13. Name of Business

15. Address of Business

17. City

18. State

19. Zip

21. Nature of Business

22. Distributor Name

24. Number of Amusement Devices
    -- Select One --12345678910111213141516171819202122232425

25. Number of Jukeboxes
    -- Select One --12345678910

27. Amusement Device Fee $50.00 Jukebox Fee $10.00

    Amusement Device Fee $50.00 Jukebox Fee $10.00

29. I depose and say that the foregoing information set forth in this license application is true and correct to the best of my knowledge and belief and do further swear and affirm that none of the machines as above described will be used as gambling devices nor will be used for any gambling of any nature whatsoever.

    I depose and say that the foregoing information set forth in this license application is true and correct to the best of my knowledge and belief and do further swear and affirm that none of the machines as above described will be used as gambling devices nor will be used for any gambling of any nature whatsoever.

31. Signature

33. Number of Amusement Devices ___________

    Number of Amusement Devices ___________

34. Number of Jukeboxes ______________

    Number of Jukeboxes ______________

36. Total $_________________

    Total $_________________

Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

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