City of Byron - Arcade Tax Survey

Arcade Tax Survey Form
Please provide the City of Byron the most current and accurate information on your business regarding amusement arcade and devices. Your arcade license approval will be based on the information given and such forms are subject to audit.

Section 1:
Business Information:
Business Name:*
Email*
example@example.com
Business Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number:*
Please enter a valid phone number.
Section 2:
Applicant and/or Interested Party Information: Please complete all information on all interested parties.
Applicant Name:*
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number:*
Please enter a valid phone number.
Home Number:*
Please enter a valid phone number.
Have you been convicted of any felony or misdemeanor?*
Are you, your spouse or any household member an employee of the Byron Police Department?*
Interested Party #1
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number:
Please enter a valid phone number.
Home Number:
Please enter a valid phone number.
Have you been convicted of any felony or misdemeanor?
Are you, your spouse or any household member an employee of the Byron Police Department?
Interested Party #2
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number:
Please enter a valid phone number.
Home Number:
Please enter a valid phone number.
Have you been convicted of any felony or misdemeanor?
Are you, your spouse or any household member an employee of the Byron Police Department?
Interested Party #3
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number:
Please enter a valid phone number.
Home Number:
Please enter a valid phone number.
Have you been convicted of any felony or misdemeanor?
Are you, your spouse or any household member an employee of the Byron Police Department?
Section 3:
Number of Machines:*
$10.00 per machine for first 9 machines: $*
NAME*
Signature*

Clear
Date*

MonthDayYear
Date
Please return completed form to the Administration Department for signature of the City Clerk. Your application will then be forwarded to the Police Chief for inspection and authorization.
Please verify that you are human*
Should be Empty:

Arcade Tax Survey Form