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Video Gaming Terminal Permit(s) Application

  1. Illinois Gaming Board Video Gaming Terminal License Numbers
    Number of Terminals to be Operated (up to six)

  2. AFFIDAVIT

    The undersigned swear or affirm that the corporation, sole proprietorship, partnership, or limited liability company in whose name this application is being made 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 that the statements contained in this application are true and correct to the best of my (our) knowledge and belief.

  3. 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.

  4. 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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