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Placement License (Juke Box or Mechanical Amusement Device) Application

  2. 4. Is any law enforcing public official, mayor, alderman, member of the City Council, or any president or member of a county board directly or indirectly interested in the business for which license is sought?*
  3. 5. Will the business be conducted by a manager or agent?*
  4. 6. Do you hold any other current business licenses issued by the City of Carbondale?*
  5. (d) Are you a citizen of the United States?
  6. (e) Have you ever been convicted of any felony under any Federal or State law?
  7. (f) Have you ever been convicted of being the keeper of a house of ill fame; or of pandering or other crime or misdemeanor opposed to decency and morality?
  8. (g) Have you ever been convicted of a violation of a Federal or State liquor law since February 1, 1934?
  9. (h) Have you ever permitted an appearance bond forfeiture for any of the violations mentioned in (e) or (g)?
  10. (i) Have you made application for a similar other license for premises other than described in this application?
  11. (j) Has any license previously issued to you by State, Federal, or local authorities been revoked?
  12. 8. List any persons, firms or organizations entitled by verbal or written agreement to a 5% or greater beneficial share of earnings or profits. If none, state "NONE". (If more than three persons, attach additional list.
  13. 9. Applicant's location of business and residence for the last 10 years.
  14. 9A. BUSINESS
  16. Affidavit*
    By checking the "I agree" box below, you swear (or affirm) that you will not violate any of the ordinances of the City of Carbondale or the laws of the State of Illinois or the laws of the United States of America, in the conduct of the place of business described herein and the statements contained in this application are true and correct to the best of your knowledge and belief.
  17. Electronic Signature Agreement*
    By checking the "I certify" box below, you certify (or declare) under penalty of perjury under the laws of the State of Illinois that the foregoing is true and correct.
  18. Electronic Signature Agreement*
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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  20. This field is not part of the form submission.