Temporary Liquor Licensing Application - City of Champaign

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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
Page 1: CITY OF CHAMPAIGN102 North Neil Str
Page 5 and 6: AFFIDAVITWe, the undersigned office
Page 7 and 8: Page 9Temporary08.13.2012

Temporary Liquor Licensing Application - City of Champaign

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