The application for the license shall contain the following information:
(A) Name, address and birth date of applicant;
(B) Prior history, if any, of criminal convictions, with a statement as to the nature of the particular conviction and the date of the conviction;
(C) Address of the premises where the machine or device is to be displayed or operated, and the nature of the business, if any, being conducted on the premises at the time of the application, or the nature of the business if a new business is contemplated; and
(D) A description of the machine or device to be covered by the license, its mechanical features, name of the manufacturer, and serial number.