Video Gaming License Application

Video Gaming License Application
Business Information
Licensed Establishment *
Address*

Street Address

CityState / Province

Postal / Zip Code
Belvidere Liquor license Number*
Contact Information
Name*

First NameLast Name
Title*
Address*

Street Address

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Terminal Operator Information
Name of Terminal Operator*
Name of Contact*

First NameLast Name
Address*

Street Address

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Number of Machines*
Copy of Establishment IL State Gaming Board License

Cancelof
Copy of Terminal Operator IL State Gaming Board License

Cancelof
I, the undersigned applicant or authorized agent thereof, swear or affirm under penalties of perjury that the matters stated in the forgoing application are true and correct, are made up on my personal knowledge and information, and are made for the purpose of requesting the City of Belvidere to issue the license herein applied for. I further swear or affirm that I have not omitted any information which is required to be made in these disclosures, that the matters stated herein are not misleading in light of the purposes for which application is made, and that the applicant is made, and that the applicant is qualified and eligible to obtain the license applied for. I further swear or affirm that the applicant will not violate any of the laws of the United States of America, the State of Illinois or the City of Belvidere relating to or regulating said business. I have read and understand the requirements stated in Chapter 14 – Amusements and Entertainments of the City Code as it pertains to video gaming. I agree to comply with all conditions stated in Article IV Video Gaming including license requirements, and indemnify and hold harmless the city from all liability lawsuits and costs. Applicant hereby acknowledges and agrees that the City retains the right under the Illinois Video Gaming Act(230 ILCS 40/1 et.seq.) to terminate all licenses and ban video gaming within the corporate boundaries of the City of Belvidere. Applicant further acknowledges that Applicant is proceeding with this application and the investment in machines, physical restructuring of premises and all other modifications necessary or helpful in establishing his, her or its video gaming business at its own risk without reliance on the part of the City or commitment there from to continue licensing of such machines or the video gaming business generally. *

Clear
If you would still like to pay with check or money order please click Submit button below and remit payment to:

City of Belvidere

401 Whitney Blvd.

Belvidere, IL 61008
Should be Empty:

Video Gaming License Application

Business Information

Contact Information

Terminal Operator Information