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~) <br /> <br />:) <br /> <br />1988 <br /> <br />(Street, BOx, Route) (City) (State~ (ZIP) <br /> <br />)) <br /> <br />~) <br /> <br />~) <br /> <br />6) <br /> <br />7) <br /> <br />Business Phone Number(s): <br /> <br />~our~ of Operation: ~ <br /> <br /> ' ' (Last ~ame) / (First ]~ame) (Middle Initial) /~0 <br /> <br /> (Street, Box, Route) (City) (State) (ZI~ <br />Applicant'~ Date of Birth: ~ -- ~-~-~ <br /> <br />8) Applicant's Position With Company: <br /> <br /> If corporation, llst below the names, residences and birthdates of those <br /> owners holding more than 5~ of the outstanding stock of the corporation: <br /> <br /> ( Last Kame) (Firs:tame) <br />11) Manager's Date of Birth: ~_/.o~ _?~ .. <br />12) Number of Devices to be Used: /~ <br />13> Types of Devices :o be U~ed: /~ ~ c/ <br /> <br />(Middle Initial) <br /> <br />14) Other cities cr co--unities where you've applied for or held a license <br /> ooerate, a similar :roe.. cf busines.:~ <br /> <br />15) Eave you, or in the case cf a Corpora:ion, the owners cf more than 5% of <br />the outstanding stoak cf the corpora:ion, been convicted of a gross =isde- <br />meancr or fe!omy r¢!a:ing to the operation of amusemen~ centers and related <br /> activities? /i-'/~ If yes, exp!aiu: <br /> <br /> <br />