Form GDR-1 Request for Registration Under the Gambling Devices Act

OMB No. 1123-0010 (02/28/2011)

REQUEST FOR REGISTRATION
UNDER THE GAMBLING DEVICES ACT OF 1962
(Please type or print legibly responses to all items.)

Date: ________________________

US Department of Justice
950 Pennsylvania Avenue, NW
Criminal Division, OEO
Gambling Device Registration Program
JCK Building, Room 1033
Washington, DC 20530-0001
Fax: (202) 353-7675
Attention: Sandra A. Holland
Dear Mrs. Holland:
I am requesting registration under the Gambling Devices Act of 1962 (15 U.S.C. 1171-1178)
for Calendar Year __________.

1.

Registrant’s name (name of business, company, organization, or individual):

2.

Trade name(s)/other name(s) registrant is doing business as (dba):

3.

Names and titles of the officer(s) or owner(s):

4.

Street address of registrant’s business location(s) or registrant’s home address, if not
engaged in business:

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Request for Registration
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5.

Address registration confirmation letter should be mailed to:

6.

Street address in a state or possession of the United States where required gambling device
records can be viewed:

7.

Activities involving gambling devices which require registration under the statute (a check
mark indicates which activities registrant intends to engage in):

______ Manufacturing

______ Repairing

______ Reconditioning

______ Buying

______ Selling

______ Leasing

______ Using

______ Making available for use by others

______ Personal home use only

Sincerely,

___________________________________
(Signature)
___________________________________
(Printed name)
Contact telephone number or email address: ___________________________________
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it
displays a valid OMB control number. The information we are collecting is mandated by 15 U.S.C. 1173. We
estimate that it will take five minutes to complete this form. If you have comments regarding the accuracy of this
estimate, or suggestions for making this form simpler, please contact us at the address given above.

DOJ\CRM\OEO\GDR-1
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