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Montgomery County Department of Health and Human Services Licensure and Regulatory Services 255 Rockville Pike, Phone: 240-777-3986 Fax:
240-777-3088 |
VIDEO GAME REGISTRATION APPLICATION
Application is hereby made
for a Video Game Registration in
New r Renewal r TODAY’S DATE____________________
Name of Establishment:_________________________________________________________________________
(List the Name of the Establishment where the games are to be operated)
Location of Establishment: ______________________________________________________________________
Street Number and Street Name
__________________________________________________________ Telephone Number:__________________
City State Zip Code include
area code
Name
of Establishment Owner/Operator:____________________________________________________________
Federal Tax
Identification #: __________________
Address of Owner/Operator:______________________________________________________________________
Street Number and Street Name
___________________________________________________________Telephone Number:__________________
City State Zip Code include
area code
Fax Telephone:__________________________Email Address:_________________________________________
Include area
code
Name and Address of Video Game Owner(s):
1. Name:__________________________________________________Telephone
Number:________________
include area code
Address:________________________________________________________________________________
Street Number and Street Name City State Zip Code
2. Name:___________________________________________________
Telephone Number:______________
include area code
Address:________________________________________________________________________________
Street Number and Street Name City State Zip Code
(Use Reserve Side if Necessary to list all video game owners)
Total Number of Games to be Registered:_______________
I understand that according to Montgomery County Code 56 a-6(d), "Any change in the information stated on the certificate of registration shall be reported to the Director within 30 days of the change."
Signature of Establishment Owner/Operator:_______________________________________Date:______________
Printed Name of Above Signature:_________________________________________________________________
Payment Method
Fee Information: Please refer to Video Game Fact Sheet
r Check r Money Order (No cash is accepted) r Visa r MasterCard (No other credit cards are accepted)
Organization: _________________________________Cardholder’s Name:______________________________
Credit Card No:_________________________________ Exp.
Date:______________ Amt:
$_______________
I agree to pay the
above total amount according to the card issuer agreement.
Cardholder’s Signature: _______________________________________________________
Submit completed application and application fee to address
at the top of the application. Checks or money orders are payable to “
OFFICE USE ONLY
Receipt Number: ______________ Date Issued: _______________
Amount Paid: _________________ Date Expires: ______________
Check/Money Order Number: ______________ Record Number: ____________