Document Text
--- Document: Application
for Amusement Games License Document ---
NJ Department of Law & Public Safety
Division of Consumer Affairs
Legalized Games of Chance Control Commission
P.O. Box 46000, Newark, NJ 07101
The Amusement Games License Application pursuant to N.J.S.A. 5:8-100 et seq.
This application must be filed in duplicate. Both copies must be filed with the municipal issuing authority with full municipal fee and a certified
check or money order, payable to the Legalized Games of Chance Control Commission, in the amount of $250.00 per state license, unless
license is for a game to be conducted at an Agricultural Fair, in which case the fee is $50.00 per license. Please note that arcades must submit an
additional fee of $10.00 per player position for each position over the original 50 positions, along with a complete list of all redemption machines.
Amended license fee is $25.00.
SECTION #1 LICENSE IDENTIFICATION
Municipality
Date Filed
Municipal License Number
Municipal License Fees $
State License Fees
$
SECTION #2 IDENTIFICATION OF APPLICANT
FOR ALL APPLICANTS: (if additional space is needed attach a notarized addendum to this application)
Name of Applicant
Mailing Address
Business
Phone #
[] Sole Proprietorship
[ ] Partnership
[] Corporation
Other [] (explain)
If applicant is an individual, provide the information requested below. If applicant is a partnership, provide the
information required in this section for each partner. If applicant, or a partner in the applicant, is a
corporation provide the information required by this section for each officer, director or stockholder of the
applicant corporation and for each officer, director or stockholder of any corporation that holds 5% or more of
the capital stock of the applicant corporation and indicate titles. Use additional sheets if necessary.
Name & Title
Date of Birth
Residence Address
(Give Exact Street Address)
Name & Title
Residence Address
(Give Exact Street Address)
Phone #
Date of Birth
Phone #
Has this person ever been convicted of a crime or violation of any law? ( ) Yes ( ) No. If yes, state details as to each
conviction, including the date of the offense, date of conviction, nature of the offense, court in which conviction was entered, and
sentence imposed.
Are there any criminal charges pending against this person? [ ] Yes [ ] No. If yes, state details as to date, place, facts leading
to arrest or indictment, and the court in which the matter is pending.
Has this person ever been disciplined or sanctioned by any authority in any jurisdiction related to any gaming or gambling
activity? [] Yes [ ] No. If yes, state details as to date, place, and facts leading to discipline or sanction, and the discipline or
sanction imposed.
Name under which business will be conducted:
SECTION #3 CORPORATE INFORMATION
FOR CORPORATE APPLICANTS: (if additional space is needed attach a notarized addendum to this application)
Corporation Name
Address
Business
Phone #
Date of Incorporation:
(Give Exact Street Address)
State of Incorporation:
[] Yes
If not incorporated
[] No
in the State of New Jersey, is the corporation authorized to do business in the State of New Jersey?
Name and address of registered agent in New Jersey upon whom service of process may be made:
Name & Title
Address
(Give Exact Street Address)
Phone #
(THIS SECTION MUST BE COMPLETED)
SECTION #4 DISCLOSURE OF COMPENSATION
Will anyone other than persons named in this application share directly or indirectly in the proceeds of the game(s) described in
this application? [ ] Yes [ ] No. This includes but is not limited to any vendor or employee who will be compensated based upon
a percentage of the proceeds of any game and any one receiving payments made based on an interest (secured or unsecured) in
any equipment or merchandise used in or in connection with the business conducted under the license for which this application
is made. If yes, please complete the information below:
Name
Address
Date of Birth
Phone#
(Give Exact Street Address)
Describe nature of payment:
SECTION #5 TYPE OF GAME; LOCATION; DATES AND TIME OF OPERATION
Name of game
Certification Number
(Type of Game) - (Give Exact Name Listed On Amusement Game Listing)
Location of game:
(Give Exact Street Address & Stand No.)
Dates of operation:
From
To
Hours of operation:
From
To
Name & Address of Landlord:
Name & Address of Owner of Premises:
(Give Exact Street Address)
(Give Exact Street Address)
SIGNATURES OF ALL PARTNERS, CORPORATE OFFICERS & DIRECTORS ARE REQUIRED
(If additional space is needed attach a notarized addendum to this application.)
AFFIDAVIT
State of:
County of:
:§
, duly sworn, upon my oath depose and say:
a.) The game(s) specified in this application will be held, operated and conducted in accordance with the Amusement Games
Licensing Law N.J.S.A. 5:8-100 et seq., ("Law") and regulations promulgated thereunder N.J.A.C.13:3-1 et seq.. ("Regulations")
b.) The information required by Section 2 of this application is either included in Section 2 or attached to and made part of this
application for each and every party having any direct or indirect interest in the amusement game(s), a license for which this
application is made.
c.) The prize (s) offered or awarded in any game shall be of merchandise only and shall be of a retail value no greater than that
set forth in N.J.A.C. 13:3-3.5 and that no prize shall be redeemable directly or indirectly for cash or money.
d.) All parties named in this application or having any direct or indirect interest in any game(s) listed in this application are of
good moral character and have never been convicted of a crime.
e.) None of the proceeds derived from the holding, operation or conduct of the game(s) described in this application shall be
paid or given directly or indirectly to any person other than those named in this application, except reasonable amounts paid for
goods, wares and services actually received in the normal course of business.
f.) No game shall be held, operated or conducted unless and until it has been certified by the Control Commission as an approved
amusement game.
g.) All statements on the foregoing application are true, accurate and complete.
Signature of Applicant - Title
Signature of Applicant - Title
Sworn and subscribed before me this
day of
Date
Month
A Notary Public
Year
Date
Date
Revised 11/01/2001
Internet - 10/11/02