Deborah Frank Feinen, Mayor & Liquor Commissioner
102 N Neil St • Champaign IL 61820 •
(217) 403-8720 • fax (217) 403-8725 •
Attachment 1
Date of Application: ____________________
Type of Application:
_____ Package Sale of Alcoholic Liquor _____ Delivery of Alcoholic Liquor _____ Growlers
Licensee Corporate Name: __________________________________________ License Category: ______
Licensee Establishment Doing Business As Name: ___________________________________
Business Address: _____________________________________________________
Business Phone Number: _______________________________________________
Manager: ___________________________________________________________________
Manager’s Phone Number: ______________________________________________
Manager’s Email Address: _______________________________________________
I certify the dramshop/liquor liability insurance related to the licensee is sufficient to fully cover the
activities and operations applied for in this form. The licensee further indemnifies the City of Champaign
and its employees and agents from any and all liability related to any and all claims that arise directly or
indirectly from Emergency Order 20-02 and any activities undertaken by the Licensee pursuant to the
I understand that I remain obligated to comply with all other requirements of the Champaign Municipal
Code and State law, including those related to verification of identity and sale of alcohol to persons age
21 and over. I further understand that additional steps may need to be taken in order to undertake any
action under the Order, including but not limited to securing the appropriate category or designation of
State liquor license.
I certify that I have authority to act as an agent of the Licensee and bind the Licensee to legal obligation.
Signed: _______________________________________________________
Printed Name: _________________________________________________
Title: _________________________________________________________
On behalf of Licensee: ___________________________________________
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