2. To the Licensing Authorities: The undersigned hereby applies for the License in accordance with the provision of the Statutes relating thereto:
3. 
5. Applicant First Name
6. Applicant Last Name
8. DBA/Business Name
10. Address of Business
12. City
13. State
14. Zip Code
16. Phone Number
18. # of Pool Tables:
19. Are they:

    1. Coin Operated
    2. Charged Hourly
    3. Free
21. Describe Location of Pool Tables:
23. Electronic Signature*
    *Typing your FULL NAME represents your official signature
24. Date
    Date

    Date
26. Email Address
28. Business Mailing Address
30. City
31. State
32. Zip Code
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit Submit and Print

* indicates a required field