Application for Amusement Device License

Application for Amusement Device License
Name of Applicant*

First NameLast Name
Address of Applicant*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Applicant*

Area CodePhone Number
Email of Applicant*
example@example.com
Name of Establishment*
Address of Establishment

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Establishment*

Area CodePhone Number
Email of Establishment*
example@example.com
Total Number of Devices*
(1 device = $50.00) ($20.00 for each additional device)
TOTAL FEE
I, _______________, state that the above information is true and correct to the best of my knowledge, and that if granted a license, I will abide by all conditions and provisions of Chapter 12.10 of the Code of ordinance of the Village & Town of Somers under which said license is issued.
Signature of Applicant*

Clear
Date Signed*

MonthDayYear
Return application and fee to:

Village/Town of Somers

Village/Town Clerk

PO Box 197

Somers, WI 53171
Office Use Only
Date Received*

MonthDayYear
License Number*
Period*
Should be Empty: