GC-01BJ
I
GC-OIBJ
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
-,
BELL JAR TICKET
DISPENSING MACIDNE
REGISTRATION
APPLICATION FORM
Instructions: Submit this application along with a photograph of the machine and an invoice, bill of sale or other
similar receipt which indicates the purchase price, date of sale and seller.
Name of Organization:
Address:
Street City
GC - m- [ITI- [ITI - ITIIJJ
N.Y.S. Identification Number
County Zip
License Number: LLCI
DESCRIPTION OF MACHINE
Name of Machine:
Manufacturer of Machine:
Model Number:
Serial Number:
PURCHASE OF EOUIPMENT
Date of Purchase:
Purchased From:
Purchase Price: $
If you are leasing your bell jar ticket machine, please attach a copy of the lease agreement.
Prepared by:
Name:
Address:
Phone:
THIS DECLARATION MUST BE COMPLETED
I declare that I am a member-in-charge of licensed bell jar ticket sales conducted by the licensee and that I
supervised the purchase of the bell jar vending machine listed above. I hereby certify that the foregoing
information and attachments are true and accurate to the best of my knowledge and belief.
Date:
Signed:
L BJ-GC-OIBJ (Rev. 4/03)
11111111111111111111111111111 -.J