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Amusement Device Fee $50.00
Jukebox Fee $10.00
I depose and say that the foregoing information set forth in this license application is true and correct to the best of my knowledge and belief and do further swear and affirm that none of the machines as above described will be used as gambling devices nor will be used for any gambling of any nature whatsoever.
Number of Amusement Devices ___________
Number of Jukeboxes ______________
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