Temporary Liquor Licensing Application - City of Champaign

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