Temporary Liquor Licensing Application - City of Champaign

CITY OF CHAMPAIGN102 North Neil StreetChampaign, Illinois 61820(217) 403-8720APPLICATION FOR CITY OF CHAMPAIGN LIQUOR LICENSE - TEMPORARYESTABLISHMENT NAMECONTACT PERSON & PHONE$30.00 Application Fee Submitted$50.00 License Fee Submitted$50.00 Refundable Deposit Submitted1. Class of License Applied for:YesYesYesNoNoNoClass T-1Class T-2Class T-3Issued to current liquor license holders for an area which the liquor licensee owns or has the right touse, which is contiguous to and which extends no further than one hundred (100) feet from thebusiness premises, for which the liquor licensee holds an existing license.Issued to any person in conjunction with an organized event or festival for the sale and consumptionof alcohol on the public way where a special events permit has been approved by the PoliceDepartment.Issued to:(a) Civic, service, charitable, or other not for pecuniary profit organizations on private property;(b) The Champaign Public Library, the Champaign Park District, or Parkland College wherepermission has been granted by the governing body of the facility pursuant to the rules ofregulation of the governing body.2. Registered name of applicant(Corporation or Association)a. Address Telephoneb. Date of incorporation State in which incorporatedc. Employer Identification No.d. If foreign corporation, date qualified to do business in Illinois under the Illinois Business CorporationActName and address of registered agent in Illinoise. Objects of corporation/association3. Type of event for which application is madePage 3Temporary08.13.2012

Date(s)/Hours during which alcohol to be served4. Address of property where event is to be helda. Is applicant owner of record of this property? If applicant is not the owner of record,give name of owner and attached the Owner Authorization Form5. Corporate officer informationa. Name – President Date of BirthResident Address (include city & zip code)Home TelephoneDriver’s License No.Stateb. Name – Vice President Date of BirthResident Address (include city & zip code)Home TelephoneDriver’s License No.Statec. Name – Secretary Date of BirthResident Address (include city & zip code)Home TelephoneDriver’s License No.Stated. Name – Treasurer Date of BirthResident Address (include city & zip code)Home TelephoneDriver’s License No.StateOthers owning more than 5% of the stock of the corporation or more than 25% of stock if publicly traded(add additional sheets if necessary):Page 4Temporary08.13.2012

a. Name Date of BirthResident Address (include city & zip code)Home TelephoneDriver’s License No.Stateb. Name Date of BirthResident Address (include city & zip code)Home TelephoneDriver’s License No.StateApplicants for temporary licenses MUST name two persons as managers, who shall be responsible forthe sale and/or service of alcoholic beverages at the event.a. Name – Manager 1 Date of BirthResident Address (include city & zip code)Home TelephoneDriver’s License No.Stateb. Name – Manager 2 Date of BirthResident Address (include city & zip code)Home TelephoneDriver’s License No.State6. Are any monies owed to the City by the applicant, whether for bills, taxes, licenses, or otherwise?Yes No If Yes, amount and length of time owed7. Is the location of the premises for which license is sought within one hundred (100) feet of any church,school, hospital, home for the aged or indigent persons, or for veterans, their wives or children, or anynaval or military station? Yes NoIf Yes, is the applicant’s place of business a hotel offering restaurant service, a regularly organized club,a food shop, or other place where the sale of liquor is not the principal business? Yes NoPage 5Temporary08.13.2012

If Yes, how long has the place of business been in operation?8. List any convictions of non-traffic violations of any ordinance or statute of any city, county, or state or ofthe Federal government indicating the name of the offense(s) and date(s) of conviction. This informationmust be provided by all persons as stated in No. 6 above (attach additional sheets as necessary).9. Has any manufacturer, importing distributor, or distributor directly or indirectly paid or agreed to pay forthis license, advanced money or anything else of value, or any credit (other than merchandising credit inthe ordinary course of business for a period not to exceed 90 days), or is such a person, or any otherperson, directly or indirectly interested in the ownership, conduct, or operation of the place of business?YesNo If Yes, give particulars10. Has any person involved with this premises for which application is made been issued a FederalWagering Stamp for the current tax year? Yes NoIf Yes, list names:11. Is any person who is a part of this application, or any other person, directly or indirectly interested in thebusiness, a public official as defined in Sec. 2(14) Art. VI of the Illinois Liquor Control Act? Yes NoIf Yes, list office held12. Name of contact person regarding this license13. Telephone number of above contact person (during regular business hours)14. Email address of contact person15. Establishment email address16. Establishment fax numberPage 6Temporary08.13.2012

AFFIDAVITWe, the undersigned officers of the above-named corporation or association, each first being duly sworn, saythat each of us has read the above and foregoing application and that the matters stated therein are true andcorrect and are made upon our personal knowledge and information, and are made for the purpose of inducingthe City of Champaign to issue the license herein applied for.We further swear that we are familiar with the liquor ordinance of the City of Champaign, the statutes of theState of Illinois, and we are responsible for the observance of all such ordinances, including City Code Sec. 5-30.1 to 5-30.3 pertaining to temporary liquor licenses, and Sec. 5-46, pertaining to age of persons servingalcoholic beverages, and service to minors and intoxicated persons, and that we will not violate any of the lawsof the City of Champaign, State of Illinois, or United States of America.We further swear that we are the duly constituted and elected officers of said applicant and as such areauthorized and empowered to execute this application for and on behalf of said applicant.PresidentVice PresidentSecretaryTreasurerSubscribed and sworn to before me thisday of ,(Notary Public)Page 7Temporary08.13.2012

CRIMINAL BACKGROUND AND CREDIT CHECK AUTHORIZATIONI authorize and empower the Liquor Commissioner of the City of Champaign or agent thereof or any otheroutside service company engaged by said Commissioner for this purpose, now or subsequently, to obtain,prepare, use, and furnish information concerning my current and former employment, education, credit,general reputation, criminal history information through correspondence, contact, or personal interviews withlaw enforcement agencies.Upon written request, I understand that said Commissioner will provide me with information regarding thenature and scope of the investigation if one is made.President(signature)Vice President (signature)Secretary(signature)Treasurer(signature)Manager 1(signature)Manager 2(signature)All others owning more than 5% of the stock, or 25% of the stock where public traded:(signature)(signature)Document composed by:City of Champaign Mayor’s Office & Legal Dept.102 N. Neil St., Champaign, IL 61820J:\CMO\LIQUOR\Liquor License App - TEMPORARY 08.13.2012Page 8Temporary08.13.2012

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