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2. City Clerk's Office
   (712) 328-4616
4. First Name
5. Last Name
7. Address
9. City
10. State
11. Zip
13. Name of Business
15. Address of Business
17. City
18. State
19. Zip
21. Nature of Business
22. Distributor Name
24. Number of Amusement Devices
    -- Select One --12345678910111213141516171819202122232425
25. Number of Jukeboxes
    -- Select One --12345678910
27. Amusement Device Fee $50.00 Jukebox Fee $10.00
29. 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.
31. Signature
33. Number of Amusement Devices ___________
34. Number of Jukeboxes ______________
36. Total $_________________
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39. Email address

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