Fillable COIN-OP DEVICE FORM Please complete this form to (Village of Wheeling)

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COIN-OP DEVICE FORM Please complete this form to (Village of Wheeling)

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COIN-OP DEVICE FORM
Revised 2/1/2021
2 Community Boulevard phone: 847.459.2620 ● fax: 847.459.2656
Wheeling, IL 60090 www.wheelingil.gov
Please complete this form to list each coin-operated device to be licensed in the Village of Wheeling.
1. BUSINESS INFORMATION
Business Name (DBA):
Wheeling Business License #:
Business Address:
2. COIN-OPERATED DEVICES
Location Name
Location Address
Potentially Hazard (F3)
Other Amuse (F2)
Cigarette
Amusement
Coffee, Sandwich, Etc.
Juke, Game, Etc.
(F1)
(F5)
$14.00 $70.00 $28.00 $105.00 $56.00
TOTAL DEVICES
PRICE PER DEVICE
TOTAL AMOUNT
0
$0.00
0
$ 0.00
0
$ 0.00
0
$ 0.00
0
$ 0.00
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COIN-OP DEVICE FORM Please complete this form to (Village of Wheeling)

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Completed 20 March 2021

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