LICENSE NO. _____________
AFFIDAVIT OF MANAGER OF LIQUOR ESTABLISHMENT:
NAME OF ESTABLISHMENT ____________________________________________________________
ESTABLISHMENT ADDRESS__________________________________________ZIP CODE__________
THE UNDERSIGNED, ON OATH STATES AND AVERS AS FOLLOWS:
1) That the matters and things set out in this statement are true.
2) That I am Manager of the business operated under the above indicated liquor license and of the
premises covered thereby.
3) That I am a resident of the City of Decatur, Illinois and a citizen of the United States. A COPY
OF A VALID ILLINOIS DRIVER LICENSE OR STATE ID MUST BE PROVIDED.
4) That I have not been convicted of a felony under any Federal or State law, convicted of keeping a
place of prostitution or keeping a place of juvenile prostitution, or convicted of pandering or other
crime or misdemeanor opposed to decency and morality, such that I am ineligible to receive a
license under the provisions of the Illinois Liquor Control Act of 1934, as amended; and am
otherwise eligible for a liquor license under said Act were I to apply for such license.
MANAGER’S NAME___________________________________________ DATE OF BIRTH___________
(Please Print)
MAIDEN NAME_______________________________________________
HOME ADDRESS_____________________________________________________ZIP CODE__________
HOME PHONE NUMBER____________________ CELL PHONE NUMBER_________________
EMAIL ADDRESS______________________________________________
MANAGER’S SIGNATURE_________________________________________________________
Signature must be notarized before returning form to City Clerk.
STATE OF ILLINOIS )
)SS
COUNTY OF MACON )
SUBSCRIBED AND SWORN TO BEFORE ME THIS ____ DAY OF _______________, ________
(SEAL) ________________________________________
NOTARY PUBLIC
CITY OF DECATUR, ILLINOIS
City Clerk
#1 Gary K. Anderson Plaza Decatur, IL 62523-1106
Phone: 217-424-2708
Fax: 217-450-2297
