BUSINESS LICENSE APPLICATION
APPLICATION NO. ________________ ANNUAL LICENSE FEE DUE MAY 1ST: $______
(PLEASE TYPE OR PRINT)
1. Applicant’s Name: _____________________________ PHONE ( )____________
2. Applicant’s Address ________________________________________________________________
City ______________________________________ State ____________ ZIP ___________
3. Length of resident at above address _______ years ________ months
4. Applicant’s Date of Birth ____/_____/________ Social Security No. _________________
5. Marital Status______________ Name of Spouse ________________________________
6. Citizenship of Applicant ___________________________
7. Business Name ________________________________ PHONE ( )___________________
8. Business Address ______________________________________________________________
City ___________________________ State ________________ ZIP ____________
9. Length of Employment _________ years _________ months
10. All residences and addresses for the last three (3) years if different than above: _______________
_____________________________________________________________________________________
______________________________________________________________________________________
11. Name and Address of employers during the last three (3) years if different than above: _________
_____________________________________________________________________________________
_____________________________________________________________________________________
12. List the last three (3) municipalities where applicant has carried on business immediately preceding the date of application: ________________________________________________________________
_____________________________________________________________________________________
13. A description of the subject matter that will be used in the applicant’s business: ______________
_____________________________________________________________________________________
14. Has the applicant ever had a license in this municipality? [ ] Yes [ ] No
If so, when ______________________
15. Has a license issued to this applicant ever been revoked? [ ] Yes [ ] No
If “yes”, explain: _____________________________________________________________________
16. Has the applicant ever been convicted of a violation of any of the provisions of this Code, etc.?
[ ] Yes [ ] No
If “yes”, explain: ____________________________________________________________________
17. Has the applicant ever been convicted of the commission of a felony? [ ] Yes [ ] No
If “yes”, explain: _____________________________________________________________________
18. LICENSE DATA: Term of License _______________________________________
Fee for License $______________
Sales Tax Number ______________________________________
License Classification ___________________________________
19. LIST ALL OWNERS IF LICENSE IS FOR LOCAL BUSINESS (PERMANENT):
__________________________________ _____________________________________
__________________________________ _____________________________________
OFFICIAL BUSINESS LICENSE
STATE OF ILLINOIS )
COUNTY OF WILLIAMSON ) ss.
CITY OF JOHNSTON CITY )
ILLINOIS SALES TAX NUMBER _______________________
TO ALL TO WHOM THESE PRESENTS SHALL BECOME GREETINGS:
WHEREAS ________________________________________________, having complied with all the requirements of the laws of the State of Illinois and the ordinances of the City of Johnston City, Illinois in this behalf made and required license is, by authority of the City of Johnston City, Illinois given and granted to the ____________________________ to __________ at __________________ in the City of Johnston City, County of Williamson, and State of Illinois, from the _______ date hereof until the __________ day of ________________, ______, said ____________________ to be subject to all laws of the State of Illinois and all ordinances of the City of Johnston City, Illinois, not in conflict therewith, which are now or hereafter may be in force touching the premises.
(L.S.)
Given under the hand of the Mayor of the City of Johnston City, County of Williamson, Illinois and the seal thereof, this ____________ day of __________________________, ______.
____________________________________
MAYOR
CITY OF JOHNSTON CITY
COUNTERSIGNED:
__________________________________
CITY CLERK
CITY OF JOHNSTON CITY
(SEAL)
APPLICANT/FIELD CHECK
INFORMATION CARD
_______________________________ _____________________________________
Name Location Date Time
_______________________________ ______________________________________
Residence Address D.L.#
_______________________________ ______________________________________
Business Address Vehicle Color Yr. Body License Info
_______________________________ ______________________________________
Occupation Vehicle Modifications:
_______________________________ ______________________________________
Social Security Number
_______________________________ ______________________________________
Race Sex Height
_______________________________ ______________________________________
Action Leading to Check:
_______________________________ _______________________________________
Weight Eyes Hair
_______________________________ _______________________________________
Complexion Date of Birth
_______________________________ _______________________________________
Unusual Features:
_______________________________ _______________________________________
_______________________________ _______________________________________
_______________________________ Comments: _____________________________
_______________________________ _______________________________________
_______________________________ _______________________________________
_______________________________ _______________________________________
_______________________________ _______________________________________
Hat Coat
Associates:
_______________________________ _______________________________________
Cap Jacket
_______________________________ _______________________________________
Blouse Dress
_______________________________ _______________________________________
Shirt Sweater
_______________________________ _______________________________________
Skirt Trousers
RAFFLE APPLICATION
JOHNSTON CITY, ILLINOIS
1. NAME OF ORGANIZATION _______________________________________________
2. MAILING ADDRESS ____________________ CITY ________________ STATE ______
PHONE _________________________
3. CHECK TYPE OF ORGANIZATION: TAX EXEMPT ID NUMBERS:
______ RELIGIOUS _______ CHARITABLE ______ LABOR FED: ________
______ FRATERNAL _______ EDUCATIONAL ______ VETERAN STATE: ______
4. HOW LONG HAS ORGANIZATION BEEN IN EXISTENCE: _______________
5. PLACE & DATE OF INCORPORATION: __________________________________________
6. NUMBER OF MEMBERS IN GOOD STANDING: _________________________________
7. PRESIDENT/CHAIRPERSON: SECRETARY: TREASURER:
________________________________/____________________/_______________________________
8. RAFFLES MANAGER: (CANNOT BE YOUR MEMBER SERVING AS TREASURER AND MUST SIGN FIDELITY BOND ATTACHED):
NAME: _________________________________ SSN: _____________________________
ADDRESS: _________________________________ DATE OF BIRTH: _____________
CITY/STATE/ZIP: ______________________ PHONE #: ___________________
9. NUMBER OF RAFFLES TO BE CONDUCTED WITHIN 1 YEAR FROM ISSUE DATE OF THIS LICENSE? ______________________
10. TIME PERIOD DURING WHICH RAFFLE CHANCES WILL BE SOLD OR ISSUED.
BEGINNING ENDING
1. _________________________________ _________________________________
2. _________________________________ _________________________________
3. _________________________________ _________________________________
4. _________________________________ _________________________________
5. _________________________________ _________________________________
11. DATE AND LOCATION AT WHICH WINNING CHANCES WILL BE DETERMINED.
1. _________________________________ _________________________________
2. _________________________________ _________________________________
3. _________________________________ _________________________________
4. _________________________________ _________________________________
5. _________________________________ _________________________________
12. LIST EACH RAFFLE PRIZE TO BE AWARDED AND ITS RETAIL VALUE.
RAFFLE #1 _______________________________ _________________________________
RAFFLE #2 _______________________________ _________________________________
RAFFLE #3 _______________________________ _________________________________
13. LICENSE LIMITATIONS.
A. Raffle chances may be sold only within the corporate limits of Johnston City, Illinois.
B. The aggregate retail value of each prize awarded by a Licensee in a single raffle shall not exceed $1,500.00.
C. The maximum retail value of each prize awarded by Licensee in a single raffle shall not exceed $1,000.00.
D. The maximum price which may be charged for each raffle chance issued or sold shall be $10.00.
E. The maximum number of days during which chances may be issued or sold shall be 60 days.
14. APPLICANT UNDERSTANDS THAT ANY LICENSE ISSUED MAY BE SUSPENDED OR REVOKED FOR ANY VIOLATION OF THE ENABLING ACT.
SWORN STATEMENT
“The undersigned attest that the above named organization is organized not-for-profit under the law of the State of Illinois and has been continuously in existence for five (5) years, preceding date of this application, and that during this entire five (5) year period preceding date of application it has maintained a bona fide membership actively engaged in carrying out its objects. The undersigned do hereby state under penalties of perjury that all statements in the foregoing application are true and correct; that all officers, operators and workers of the games are bona fide members of the sponsoring organization and are all of good moral character and have not been convicted of a felony; that if a license is granted hereunder, the undersigned will be responsible for the conduct of the games in accordance with the provisions of the laws of the State of Illinois and this jurisdiction governing the conduct of such games.”
_________________________________
NAME OF ORGANIZATION
____________________________________________
SUBSCRIBED AND SWORN TO BY: PRESIDING OFFICER
BEFORE ME ON THIS _____________ DAY OF _________________________, 20______
_____________________________________________
BY: SECRETARY OF ORGANIZATION
_____________________________
NOTARY PUBLIC
FIDELITY BOND
KNOW ALL MEN BY THESE PRESENTS, THAT:
________________________________(hereafter called “Principal”) as Principal are held and firmly bound unto _______________________, (hereinafter called “Organization”) in the sum of $1,000.00, to be paid to the said Organization, successors or assigns, firmly by these presents.
WHEREAS, the above “Principal” has accepted the position of Raffles Manager with the said “Organization”, and by reason thereof will receive into his hands monies, goods and other property of said organization.
NOW, the condition of this obligation is such that if the “Principal” shall upon request at any time and upon the expiration of his term as Raffles Manager, render a true account of all monies, goods and other property of said “
IT IS A CONDITION OF THIS BOND THAT NOTICE IN WRITING SHALL BE GIVEN TO JOHNSTON CITY, ILLINOIS CITY CLERK, NO LESS THAN 30 DAYS PRIOR TO ITS CANCELLATION OTHERWISE IT SHALL REMAIN IN FULL FORCE!
Executed this ________ day of______________, 20_____, Johnston City, Illinois.
___________________________________________
By: Raffles Manager as “Principal”
(THE ORIGINAL OF THIS FIDELITY BOND TO BE DELIVERED TO THE CITY CLERK OF JOHNSTON CITY, ILLINOIS.)
(A COPY OF THIS FIDELITY BOND TO BE RETAINED BY THE “ORGANIZATION”.)
(2010 Code, Ch. 7, Forms) (Ord. 06-15, passed 8-11-2015)