Video Gaming Location Application - duplicate

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Basic identifying information for each location

• Name of Location License Applicant (as registered with the Illinois Secretary of State)

• FEIN # (needs to be 9 numbers)

• Doing Business As (D/B/A)

• Business Address
  Address

• City, State, & Zip

• County

• Business Phone #

• Cell Phone #

• State Department FIle #

• Incorporation Date

• Agent Name

• Agent Street Address

• E-mail

• Password (needs to be 8 characters, at least 1 number, and 1st letter capitalized)

• IGB Log in ID# (Once this number is provided, it will become the locations IGB ID going forward.

• Application For:

  Licensed Retail Establishment

  Licensed Truck Stop Establishment

  Licensed Veterans Establishment

  Licensed Fraternal Establishment.

• Applications Business Structure:

  Select Individual / Sole Proprietor Partnership LLC Corporation Publicly Held Corporation Not for Profit corporation or charitable organization Municipal Location (golf course, park facility, etc.)

  • Individual / Sole Proprietor
  • Partnership
  • LLC
  • Corporation
  • Publicly Held Corporation
  • Not for Profit corporation or charitable organization
  • Municipal Location (golf course, park facility, etc.)

Officer Info

Officer # 1 Info

• Name of Officer

• Home Address

• Any misdemeanors or felonys?

  Yes

  No

  N/A

• SSN

• Date of Birth

• Title

• Percentage if any

Officer # 2 Info

• Name of Officer

• Home Address

• Any misdemeanors or felonys?

  Yes

  No

  N/A

• SSN

• Date of Birth

• Title

• Percentage if any

Officer # 3 Info

• Name of Officer

• Home Address

• Any misdemeanors or felonys?

  Yes

  No

  N/A

• SSN

• Date of Birth

• Title

• Percentage if any

Officer # 4 Info

• Name of Officer

• Home Address

• Any misdemeanors or felonys?

  Yes

  No

  N/A

• SSN

• Date of Birth

• Title

• Percentage if any

Video Gaming Manager

• Name of Video Gaming Manager

• Home Address

• Any misdemeanors or felonys?

  Yes

  No

  N/A

• SSN

• Date of Birth

• Title

• Percentage if any

Legal Restrictions

• Is the location within 1000 ft of an Off Track Betting location

  Yes

  No

  N/A

• Is the location within 100 ft. of a school or a church?

  Yes

  No

  N/A

Disclosures

• Has applicant ever been involved in Gaming or applied for a gaming license in this state or any other State?<br><br>If so give details.<br>

  Yes

  No

  N/A

• Ever applied for a license provided by a government agency that has been denied, suspended, or revoked?

  Yes

  No

  N/A

• Does applicant owe any State or Federal taxes?

  Yes

  No

  N/A

• Has the company ever filed for bankruptcy?

  Yes

  No

  N/A

• Have any civil cases ever been filed against the company regarding debt?

  Yes

  No

  N/A

• Do you or any of the officers of the corporation, currently have any family members that hold a position in public office?

  Yes

  No

  N/A

• Has the company made any political contributions to a public official, political party and or government entity within the last 5 years?

  Yes

  No

  N/A

• Does any individual or business entity have any equity interest in the company?

  Yes

  No

  N/A

• Are you or any of the officers of the company delinquent in child custody payments?

  Yes

  No

  N/A

• How many employees does the applicant have?

  Yes

  No

  N/A

• Ever had any gaming machines in your establishment?

  Yes

  No

  N/A

Licensing Requirements

• State LIquor License #

• Expiration Date

• IBT #

• Illinois Business Authorization Location Code #

• Local LIquor LIcense #

• Expiration Date

• Authority that provided the Local LIquor License

Other

• Can location owner view IGB Gaming app online?

  Yes

  No

  N/A

• Additional notes