Temporary Liquor Licensing Application - City of Champaign

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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
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Temporary Liquor Licensing Application - City of Champaign

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