| 1.) NAME OF APPLICANT: |
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| EMAIL: |
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| MAILING ADDRESS: |
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| CITY: |
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| STATE, ZIP: |
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| 2.) TELEPHONE NUMBER: |
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| SOCIAL SECURITY #: |
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| 3.) DATE OF BIRTH : |
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| 4.) ARE YOU A US CITIZEN: |
YES
NO |
| IF NATURALIZED CITIZEN, WHEN: |
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| WHERE NATURALIZED: |
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| COURT IN WHICH (OR LAW UNDER WHICH) NATURALIZED: |
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| 5.) PLEASE LIST THE FOLLOWING, IF APPLICABLE: |
| A.) FEDERAL TAX ID #:
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| B.) STATE OF ILLINOIS TAX #:
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| C.) STATE OF ILLINOIS LIQUOR LICENSE #:
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| 6.) NAME AND ADDRESS FOR WHICH LICENSE IS SOUGHT: |
| NAME: |
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| ADDRESS: |
, Savanna, Illinois 61074 |
| ARE THESE PREMISES OWNED BY THE APPLICANT?
YES
NO |
| IF LEASED, STATE TERM THEREOF: |
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| 7.) DESCRIBE YOUR PRESENT BUSINESS FOR WHICH LICENSE IS SOUGHT: |
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8.) ESTIMATE CURRENT NON-LIQUOR INVENTORY: $
ESTIMATE CURRENT LIQUOR INVENTORY: $
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| 9.) HAS THIS COMPANY MADE SIMILAR APPLICATION FOR THIS CLASSIFICATION AT A LOCATION DIFFERENT FROM THAT DESCRIBED IN #2?
YES
NO |
| IF YES, WHAT DISPOSITION RESULTED? |
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| 10.) HAVE YOU EVER BEEN CONVICTED OF A FELONY?
YES
NO |
| A MISDEMEANOR?
YES
NO |
| IF "YES", GIVE DATE, STATE OFFENSE AND DISPOSITION: |
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11.) HAVE YOU READ TITLE 3 CHAPTER 7 OF THE SAVANNA MUNICIPAL CODE AND AGREE TO ABIDE BY IT?
YES
NO |
| DO YOU KNOW OF ANY REASON WHY
YOU WOULD NOE BE QUALIFIED TO HOLD THE LICENSE UNDER THE LAWS OF THE STATE OF ILLINOIS AND THE ORDINANCES OF THE CITY OF SAVANNA?
YES
NO |
12.) HAS ANY PREVIOUS LIQUOR LICENSE BEEN ISSUED TO YOU BY ANY STATE OR SUBDIVISION THEREOF, OR BY THE FEDERAL GOVERNMENT BEEN REVOKED?
YES
NO |
| IF "YES', PLEASE STATE DISPOSITION: |
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| 13.) HAVE YOU EVER VIOLATED ANY LAWS OF THE STATE OF ILLINOIS, OR ANY LAWS OF THE UNITED STATES, OR ANY ORDINANCES OF THE CITY OF SAVANNA, ILLINOIS RELATIVE TO THE SALE OF INTOXICATING LIQUORS? |
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YES
NO |
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| IF "YES", PLEASE STATE DISPOSITION: |
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| 14.) ATTACH CURRENT COPY OF DRAM SHOP INSURANCE CERTIFICATE (please submit this either electronically [coming soon] or at City Hall, 101 Main St., Savanna, Il 61074) |
| State of Illinois ) |
| SS. |
| Carroll County ) |
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| I (or we) swear (or affirm) that I (or we) will not vioate any of the ordinances of the City of Savanna 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 cotained in this application are true and correct to the best of my (our) knowledge and belief. |
__________________________________________________
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| Signature of Applicant |
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| Subscribed and Sworn to before me this ________ day of _______________, 2______. |
__________________________________________________
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| Notary Public |
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| License Approved this ________ day of ________________, 2______. |
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| By _____________________________________________________ |
| Mayor of Savanna |
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