VIDEO GAMING LOCATION LICENSE APPLICATION
I, (we), the undersigned hereby make application for a Video Gaming Terminal License as define by the Illinois Video Gaming Act 230 ILCS 40/1 et seq. and in accordance with Ord. 2012-9-3.
SECTION A: Information Regarding the Applicant:
Applicant’s Name(s): __________________________________________________
__________________________________________________
Applicant’s Contact Information Telephone # _______________________________
Cell Phone # _________________________________
Applicant’s Address: __________________________________
City: __________________ State: ________________ Zip: ________________
Applicant’s Signature(s) __________________________________________________
__________________________________________________
SECTION B: Information Regarding the Liquor License Holder’s Establishment
Name of Business:_______________________________________________________
D/B/A:________________________________________________________________
Business Address:_______________________________________________________
Mailing Address:________________________________________________________
Web Site Address: ___________________ Email Address: _____________________
Telephone # ______________ Fax # _____________ Cell #_______________
Retail Sales # _______________________ Federal Tax I.D. #36-________________
No. of Gaming Terminals (only five terminals allowed per establishment): ________
Owner of Building: ___________________ Night # _______________________
Owner’s Address: ______________________________________________________
City: __________________ State: ________________ Zip: _______________
Manager’s Name: _____________________ Telephone # ____________________
In Manager’s absence, person in charge _____________________________________
Telephone # ___________________________________________________________
Section C: Information Regarding Gaming License
Illinois State Gaming Board Terminal License Numbers for each terminal:
Terminal (1): # ______________________ Terminal (4): # ______________________
Terminal (2): # ______________________ Terminal (5): # ______________________
Terminal (3): # ______________________
Serial Numbers for each terminal:
Terminal (1): # ______________________ Terminal (4): # ______________________
Terminal (2): # ______________________ Terminal (5): # ______________________
Terminal (3): # ______________________
FOR OFFICE STAFF ONLY |
Documentation Check List |
Copy of the license issued by the Illinois Gaming Board |
City of Mount Carroll Liquor License number _______________________ |
City of Mount Carroll Liquor License expiration date ___________________ |
Approved _______________________ Denied _______________________ |
Authorized Staff Signature _______________________ |
Approval Date _________________________________ |
(Ord. 5-89-2, passed 5-9-1989)