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Spect Ave. PO Box 201424 Helena, MT 59620-1424 Phone: (406) 444-1971 Fax: (406) 444-9157 Type or print legibly using blue ink. Activity from Video Gambling Machines, permitted for play, owned by the Route Operator named on this form and in the location listed below, will be reported using the Route Operator s approved automated accounting and reporting system. ROUTE OPERATOR INFORMATION: NAME CONTACT NAME ACCOUNT NUMBER (000000-XXX-MDR) E-MAIL ADDRESS OF CONTACT PHONE NUMBER.

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