Form Center

2. TO THE CITY MANAGER, CITY OF CARBONDALE:
4. The undersigned hereby makes (make) application for the issuance of a City License to allow placement of a Juke Box or Mechanical Device (as defined in City Ordinance 1475), for the term ending:*
6. 1. Applicant's full name*
7. Applicant's address*
9. 2. Address for placement of juke box or mechanical amusement device*
10. Business phone*
12. 2A. Exact address by street and number*
13. Zip*
15. 2B. Full description of location, place of premises, specifying floor, room, etc.*
17. 3. State principal kind of business*
19. 4. Is any law enforcing public official, mayor, alderman, member of the City Council, or any president or member of a county board directly or indirectly interested in the business for which license is sought?*

    1. Yes
    2. No
21. 5. Will the business be conducted by a manager or agent?*

    1. Yes
    2. No
23. Name of manager or agent
24. Residence address
26. 6. Do you hold any other current business licenses issued by the City of Carbondale?*

    1. Yes
    2. No
28. If so, what type of license do you currently hold?
29. Address of the licensed premises
31. 7. Individual applicant and all persons sharing in profits as specified in paragraph 8 must answer question No. 7. If more than applicant, identical information must be completed for each additional person and attached hereto.
33. 7A(a) Name
34. DOB
36. (b) Residence address
38. (c) Phone
39. Place of birth
41. (d) Are you a citizen of the United States?

    1. Yes
    2. No
43. If a naturalized citizen, when naturalized? (Month/Day/Year)
44. Where naturlized? (City and State)
46. Court in which (or law under which naturalized)
48. (e) Have you ever been convicted of any felony under any Federal or State law?

    1. Yes
    2. No
50. If so, give date and state offense
52. (f) Have you ever been convicted of being the keeper of a house of ill fame; or of pandering or other crime or misdemeanor opposed to decency and morality?

    1. Yes
    2. No
54. If so, give dates and state offense
56. (g) Have you ever been convicted of a violation of a Federal or State liquor law since February 1, 1934?

    1. Yes
    2. No
58. If so, give dates and state offense
60. (h) Have you ever permitted an appearance bond forfeiture for any of the violations mentioned in (e) or (g)?

    1. Yes
    2. No
62. (i) Have you made application for a similar other license for premises other than described in this application?

    1. Yes
    2. No
64. If so, give date, location of premises and disposition of application
66. (j) Has any license previously issued to you by State, Federal, or local authorities been revoked?

    1. Yes
    2. No
68. If so, state reason thereof and date of revocation
70. 8. List any persons, firms or organizations entitled by verbal or written agreement to a 5% or greater beneficial share of earnings or profits. If none, state "NONE". (If more than three persons, attach additional list.
71. Attach
73. Name
74. Residence Address
76. Name
77. Residence Address
79. Name
80. Residence Address
82. 9. Applicant's location of business and residence for the last 10 years.
84. 9A. BUSINESS
86. Name
87. Address
88. Type
89. Dates (from-to)
91. Name
92. Address
93. Type
94. Dates (from-to)
96. Name
97. Address
98. Type
99. Dates (from-to)
101. 9B. RESIDENCE
103. Name
104. Address
105. Type
106. Dates (from-to)
108. Name
109. Address
110. Type
111. Dates (from-to)
113. Name
114. Address
115. Type
116. Dates (from-to)
118. 10. Name and address where machine is to be placed*
120. 11. Type of Business*
122. 12. Type of Machine*
124. 13. Name of Manufacturer*
126. 14. Serial No.*
128. Affidavit*

     By checking the "I agree" box below, you swear (or affirm) that you will not violate any of the ordinances of the City of Carbondale or the laws of the State of Illinois or the laws of the United States of America, in the conduct of the place of business described herein and the statements contained in this application are true and correct to the best of your knowledge and belief.

     1. I agree.
130. Electronic Signature*
132. Electronic Signature Agreement*

     By checking the "I certify" box below, you certify (or declare) under penalty of perjury under the laws of the State of Illinois that the foregoing is true and correct.

     1. I certify.
134. Electronic Signature*
136. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
138. Electronic Signature*
140. Email*
Leave This Blank:


147. 1. Receive an email copy of this form.
148. Email address

     This field is not part of the form submission.

149. Submit

* indicates a required field