Form ADT
                        Application for Amusement Device Permit
                                                                       State Use Only
Mail application and payment to:
Idaho State Tax Commission
PO Box 36
Boise ID  83722-0410

Use this application for amusement device permits (decals). You must display decals on each currency- or token- 
operated amusement device in service. Examples: pinball machine, jukebox, video game, etc. 
Legal business name                                           Assumed business name

Mailing address                                               Employer Identification Number (EIN ) Social Security number (SSN)

City                                          State           ZIP code                 Business phone number

Contact Person Information
Name                                          Title                                    Phone number and extension

Email address                                                                          Fax number

Section 1
1. Purpose of registration (select one):
         New applicant            Change legal name           Change assumed business name
                                  Add/Change location         Change in partners, shareholders, or managing members

2.  Enter your active Idaho seller’s permit number, if applicable.
If you have a current Idaho seller’s permit and information about your business hasn’t changed, go to section 2.  
3. Date business began in Idaho 4. Date incorporated          5. State of incorporation             6. Month tax year ends

7. Describe your business activities in Idaho. Include the date the activities began in Idaho.

8. Have you ever had a permit or account number issued by us?          If yes, list all permit or account numbers.

         Yes            No

9. Type of business (select one):
              Sole proprietorship     Partnership                 S corporation                     Corporation
              Nonprofit               Government                  Fiduciary or trust                Limited liability company

10.  List (a) owner and spouse of sole proprietorship, (b) all partners of partnership, (c) all corporate officers for a 
corporation, or (d) all members for an LLC.  (Use additional sheet, if necessary.)
                Name                          Address of residence     SSN or EIN and phone number  Corporate    %              Director?
                                                                                                    Title        Owned          yes/no

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                                                                                  Form ADT    (continued)          

Section 2
11. List the business’s physical location - No PO Box or mail drop addresses
(Use additional sheet, if necessary.)
Street address                                City                          State               ZIP code

Street address                                City                          State               ZIP code

Street address                                City                          State               ZIP code

12. If you operate amusement devices at locations other than your own business, please include below.
(Use additional sheet, if necessary.)
Device 1
Street address                                City                          State               ZIP code

Device 2
Street address                                City                          State               ZIP code

Device 3
Street address                                City                          State               ZIP code

Section 3
13. Enter the number of amusement device decals requested. See instructions for decal requirements.
 Number of decals for machines or devices in service      x $42.00 =                                    Total Due

Section 4
Complete the applicable section if you’re requesting a transfer of existing decals (see instructions for transfer types).

14.  Are you the new owner of a business with existing decals registered to the previous owner?     Yes No

 Enter the previous owner’s name:

 Enter the date you acquired the business:

 List of decals to be transferred:

15. Did you change the name of your business? Yes       No

 Provide your business’s previous name:

 List of decals to be transferred:

Certification: I certify that I am authorized as an owner, partner, corporate officer, member, or representative to sign 
this document and that the statements made are correct and true to the best of my knowledge. (For sole proprietors, the 
spouse must also sign this form.)
Print name                                    Signature                                         Date

Print name                                    Signature                                         Date

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