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Video Gaming Application (CITY OF KANKAKEE IL)

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CITY OF KANKAKEE
VIDEO GAMING LOCATION LICENSE APPLICATION
I (we) the undersigned herby make application for a Video Gaming Terminal
License as defined by the Illinois Video Gaming Act 230 ILCS 40/1, et seq and in
accordance with City Ordinance No. 18-37.
SECTION A: Information Regarding the Applicant
Applicant’s Name(s): ____________________________________________________________
____________________________________________________________
Applicant’s Contact Information Telephone # _________________ Cell # __________________
Applicant’s Address: ____________________________________________________________
City: ________________________ State: _____________ Zip:__________________
Manager’s Name:__________________ Telephone # _____________Cell #________________
Applicant’s Signature(s) _________________________________________________________
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 (6 allowed per establishment, 10 allowed per large truck stop
1
): _____
SECTION B: Owner of Video Game Terminals
Name of Business:______________________________________________________________
Business Address:_______________________________________________________________
Mailing Address:________________________________________________________________
Web Site Address:_______________________________________________________________
Email Address:_________________________________________________________________
Telephone #___________________Fax #___________________Cell #___________________
Retail Sales #________________________Federal Tax I.D. #36-________________________
No. of Gaming Terminals (6 allowed per establishment, 10 allowed per large truck stop): ______
SECTION C: Information Regarding Gaming License
Illinois state Gaming Board Terminal License Numbers for each terminal:
Terminal (1): #_______________________ Terminal (6): #_______________________
Terminal (2): #_______________________ Terminal (7): #_______________________
Terminal (3): #_______________________ Terminal (8): #_______________________
Terminal (4): #_______________________ Terminal (9): #_______________________
Terminal (5): #_______________________ Terminal (10): #______________________
Serial Numbers for each terminal:
Terminal (1): #_______________________ Terminal (6): #_______________________
Terminal (2): #_______________________ Terminal (7): #_______________________
Terminal (3): #_______________________ Terminal (8): #_______________________
Terminal (4): #_______________________ Terminal (9): #_______________________
Terminal (5): #_______________________ Terminal (10): #______________________
1
Large Truck Stop: A facility located within three (3) road miles from a freeway interchange, as measured in
accordance with the Department of Transportation’s rules regarding the criteria for the installation of business signs,
(i) that is at least a 3-acre facility with a convenience store, (ii) with separate diesel islands for fueling commercial
motor vehicle, (iii) that sells at retail more than 50,000 gallons of diesel or biodiesel fuel per month, and (iv) with
parking spaces for commercial motor vehicles.
For Office Use Only
DOCUMENTATION CHECK LIST
Copy of Illinois Gaming Board’s Application: Yes No
Copy of the license issued by the Illinois Gaming Board: Yes No
City of Kankakee Liquor License #:
City of Kankakee Liquor License expires on:
Approved: Denied:
Authorized Staff Signature:
Approval Date:
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Video Gaming Application (CITY OF KANKAKEE IL)

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Completed 14 July 2020

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