14.180
PURCHASER'S STATEMENT
I, _______________________, declare under penalty of
perjury that each gaming device, as identified more fully on the attached Regulation
14.180 Application, will be used only for lawful purposes,
specifically_____________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
(describe intended use)
I acknowledge that all subsequent distribution of these devices must conform to all local, state, federal and foreign laws.
_____________________________
Print Name
_____________________________
Signature of Purchaser
_____________________________
Date