Every application for a license to operate a pool and/or billiard room shall be in writing and shall be in the following form:
            Roxboro, N.C.
To the Mayor and City Council
City of Roxboro
Roxboro, North Carolina
   "I (we), do hereby make application for license to operate a pool and/or billiard room in the City of Roxboro at the following location:                                                
   Accompanying this application is a duly certified bank check or cash in the amount required as a privilege license fee for the current fiscal year for                 (number of) tables, that being the number that I (we) expect to operate at said location.
   If said license be granted, I (we) agree to observe all ordinances, rules, and regulations of the city in respect to the operation of pool and/or billiard rooms, and I (we) expressly agree and consent to all provisions contained in the ordinances of said city with respect to granting and revoking a privilege license, and I (we) waive any claim for refund of any part of the money paid by me (us) for license in case the said license should be revoked under the provisions of ordinances passed by the city either heretofore or hereafter.”
(`90 Code, § 5-51)