__________________________________
Name of Manager
_______________________________________________________________
Date of Birth
_______________________
First MI Last
Address
__________________________________________________________________________________________________________________
Street City State Zip Code
Owner/Distributor of video terminals to be licensed:
Name
____________________________________________________________________________
Phone #
_______________________________
Business Name or First, MI, & Last Name
Address
__________________________________________________________________________________________________________________
Street City State Zip Code
Email Address _______________________________________________________________________
Person or business that will service or maintain video terminals to be licensed (if different):
Name
____________________________________________________________________________
Phone #
_______________________________
Business Name or First, MI, & Last Name
Address
__________________________________________________________________________________________________________________
Street City State Zip Code
Email Address _______________________________________________________________________
THE UNDERSIGNED, BEING FIRST DULY SWORN, ON OATH DEPOSES AND SAYS:
(Please initial after each)
1. The Establishment is not in arrears in any taxes, fees, or bills due to the City of Decatur or
State of Illinois. _________
2. The establishment agrees to observe all requirements of Chapter 54.1 of the City Code and
abide by all other ordinances and laws of the State, Federal, and Local Government. ______
3. That no owner with more than a five percent (5%) interest or manager of the establishment
has ever been convicted of a felony, a gambling offense, or a crime of moral turpitude or has
applied for a Certificate of Rehabilitation from the City Manager._________
4. Does hereby state under penalties of perjury that all statements in the foregoing application
are true and correct. _______
PLEASE PRINT
Name______________________________________________________Phone #______________
First MI Last
Address_________________________________________________________________________
Address City State Zip Code
Date of Birth______________________ Signature____________________________________
STATE OF ILLINOIS )
) SS.
COUNTY OF MACON )
Subscribed and sworn to before me this ________day of ____________________________, 20_____.
Notary Public
(Seal)
