Skills Based Amusement Device Registration Form Please complete this form to register your amusement devices. This form is due every other year by December 31. Owner Information Company Name Doing Business As (if different) First Name Last Name Phone Email Street Address City State Zip Code County Point of Contact Information This is where all certificates and stickers will be sent. First Name Last Name Phone Email Job Title Street Address City State Zip Code Location Information This is where devices are physically operated. How many locations do you operate? Only One LocationMultiple Locations Location Name Street Address City State Zip Code County Please fill out and attach this spreadsheet detailing the name, address, and point of contact information for each location. If you already have this information in a neatly formatted PDF file, you may upload that file instead. Device Information Please complete the areas below for all of your machines that award prizes. Machine types include redemption, merchandiser, and other similar skills-based amusement devices. Skills-based amusement devices may not award a prize with a wholesale value that exceeds $40. Code of Maryland Regulations 36.08.04.01 provides additional standards for skills-based amusement devices. Redemption Devices A device, such as a Skee-Ball or other machine, by which players receive tickets, tokens, or other objects that can be converted into prizes. Number of Redemption Devices: Maximum wholesale value of a single prize awarded: Merchandiser Devices A device, such as a claw/crane machine, by which players control a claw or other device to retrieve prizes. Number of Merchandiser Devices: Maximum wholesale value of a single prize awarded: Other Skills-Based Amusement Devices Other devices by which players use their skills to redeem prizes. Number of Other Skills-Based Devices: Maximum wholesale value of a single prize awarded: Devices That Do Not Award Prizes Number of skills-based machines that do not award prizes: Proof of Admissions & Amusement Taxes Please attach a PDF copy of your most recent filing of the Admissions and Amusement Tax. If you are unable to provide this documentation in PDF format, please email your documentation to [email protected] prior to submitting this form. Your application will not be processed without this documentation. Additional Information Registration must be completed every other year in accordance with Code of Maryland Regulations 36.08.02.01. Devices are subject to inspection by Maryland Lottery and Gaming. Upon registration, Maryland Lottery and Gaming will issue registration stickers that you must place on each of your devices in an area visible to inspection. I certify that the answers and documentation provided are true and complete to the best of my knowledge.
