10
04 9
th
Avenue North, Texas City, TX 77590-7407
www.texas-city-tx.org (409) 948-2525
1
TEXAS CITY POLICE DEPARTMENT
Name of Applicant:
Date of Birth:
Address:
Telephone No.
Driver License No.
Social Security No.
Name of Business:
Location of Business:
At
tach additional pages if more than one owner of the business, owns 25% or more.
A c
opy of the applicants’ DBA, if applicable
If
a previous license or permit of applicant, or, if applicable, corporate officer or partner of applicant, has
been revoked with two (2) years of filing of the application.
Num
ber of amusement redemption machines at the above given address. __________.
Name, Address and Telephone Numbers of all owner(s) of machines:
Business Name of Vending Company:
Telephone Number(s) of Vending Company:
State Vending Permit Number of License:
List all Amusement Redemption Machines that are to be used on the premises:
(Additional pages may be added)
Location of Machine
Make
Model
Serial Number
Application for Coin Operated Amusement Redemption Machine
FRAUDULENT / FALSE INFORMATION WILL RESULT IN IMMEDIATE DISQUALIFICATION
(Illegible and/or incomplete applications will be denied)
Pe
rmit / License
1004 9
th
Avenue North, Texas City, TX 77590-7407
www.texas-city-tx.org (409) 948-2525
2
The following statements must be completed:
The amusement redemption machines are not and will not be used as gambling devices:
All the facts contained in the application are true and correct:
The location and operation of the amusement redemption machine will not violate any applicable
deed restrictions:
The amusement redemption machine game room will be operated in accordance with all laws:
Total
number of machines in this establishment: _____
Name,
address and telephone number(s) of an emergency contact person who can be reached after
hours:
____________________________________________________________________________________
__________
__________________________________________________________________________
Store Owner Signature: _____________________________________ Date: ______________________
Machine Owner Signature: __________________________________ Date: ______________________
Texas City Police Department
Records Department: ______
All payments must be made by check, cashiers check or money order.
$115 per
Machine
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