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: (406) 444-1971 Fax: (406) 444-9157 Check Amt $ Refund $ FEE SCHEDULE EFFECTIVE JULY 1, 2005 Submit correct fee per machine: July 1 through June 30 $220 per machine Oct. 1 through June 30 $165 per machine Jan. 1 through June 30 $110 per machine April 1 through June 30 $55 per machine AN IMPROPERLY COMPLETED OR INCOMPLETE APPLICATION WILL BE RETURNED. Type or print legibly using blue ink. GAMBLING ACCOUNT ID NUMBER (0000000-000-XXX) ESTABLISHMENT PHONE NUMBER Ma.

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