Distributor License Application for Amusement Device & Jukebox

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

   (712) 328-4616

4. Annual Renewal Fee: $100
   Submit a check or money order to: City Clerk 209 Pearl St. Council Bluffs, IA 51503

   Submit a check or money order to: City Clerk 209 Pearl St. Council Bluffs, IA 51503

6. Applicant

8. Address

10. Place of birth

11. Date of birth

15. Please list prior convictions except for traffic violations

17. I hereby certify that I am of good moral character and a citizen of the United States.

19. Applicant signature

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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit Submit and Print

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