Form Center

2. Total Number of Machines*
   -- Select One --123456More than 6
3. Total Due ($250 per machine)*
   -- Select One --1 = $2502 = $5003 = $7504 = $1,0005 = $1,2506 = $1,500More than 6
5. Name of Entity (i.e. corporation, individual, etc.) that holds the State Video Gaming License*
7. Name of the Establishment:*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Establishment Phone Number*
16. Contact Cell Number*
18. Email Address*
20. Check days of operation*

    1. Sunday
    2. Monday
    3. Tuesday
    4. Wednesday

    1. Thursday
    2. Friday
    3. Saturday
22. Hours of Operation: Sunday*
24. Hours of Operation: Monday*
26. Hours of Operation: Tuesday*
28. Hours of Operation: Wednesday*
30. Hours of Operation: Thursday*
32. Hours of Operation: Friday*
34. Hours of Operation: Saturday*
36. Please upload a copy of the State Video Gaming License*
38. License Type
    Video Gaming
39. Cost per Machine
40. Quantity*
41. Shipping Cost
43. Taxable
Leave This Blank:


45. Calculate Totals Proceed to Checkout

* indicates a required field