CITY OF CARROLLTON BUSINESS LICENSE APPLICATION APPLICATION NO. _________________ LICENSE FEE: $ (PLEASE TYPE OR PRINT) 1. Applicant’s Full Name:______________________________________ PHONE ( ) 2. Applicant’s Address City_________________________________ State_______________ ZIP 3. Length of resident at above address ________years ____________months 4. Applicant’s Date of Birth ___/___/___ Social Security No. 5. Marital Status ___________________ Name of Spouse 6. Maiden Name (if applicable) 7. Citizenship of Applicant 8. Business Name 9. Business Address City_________________________________ State_______________ ZIP 10. Length of Employment _________years _____________months 11. All residences and addresses for the last three (3) years if different than above: ______________________________________________________________________ ________ ______________________________________________________________________ ________ 12. Name and Address of employer(s) during the last three (3) years if different than above: ______________________________________________________________________ ________ ______________________________________________________________________ ________ 13. List the last three (3) municipalities where applicant has carried on business immediately preceding the date of application: ______________________________________________________________________ ________ 14. A description of the subject matter that will be used in the applicant’s business: ______________________________________________________________________ ________ 15. Has the applicant ever had a license in this municipality? [ ] Yes [ ] No If so, when ___________________________________________________________________ 16. Has a license issued to this applicant ever been revoked? [ ] Yes [ ] No If “yes”, explain: ______________________________________________________________ 17. Has the applicant ever been convicted of a violation of any of the provisions of this Code, etc.? [ ] Yes [ ] No If “yes”, explain: ______________________________________________________________________ ________ 18. Has the applicant ever been convicted of the commission of a felony? [ ] Yes [ ] No If “yes”, explain: 19. LICENSE DATA: Term of License Fee for License $ Sales Tax Number 20. LIST ALL OWNERS IF LICENSE IS FOR LOCAL BUSINESS (PERMANENT): ___________________________________ ___________________________________ ___________________________________ ___________________________________ 21. Do you have a federal employer identification number? Please list number: 22. State your Retailer Occupation Tax Number: CITY OF CARROLLTON, ILLINOIS OFFICIAL BUSINESS LICENSE STATE OF ILLINOIS ) COUNTY OF GREENE ) ss. CITY OF CARROLLTON ) ILLINOIS SALES TAX NUMBER TO ALL TO WHOM THESE PRESENTS SHALL BECOME GREETINGS: WHEREAS , having complied with all the requirements of the laws of the State of Illinois and the ordinances of the City of Carrollton, Illinois, this required license is, by authority of the City of Carrollton, Illinois given and granted to the owner(s) of , to conduct business as at the location of , in the City of Carrollton, County of Greene, from this date forward until any change in ownership, location, or purpose of business makes the information submitted on the business license application incomplete or inaccurate. This license may also be revoked upon a violation of the laws of the United States of America, State of Illinois or ordinances of the City of Carrollton. Given under the hand of the Mayor of the City of Carrollton, County of Greene, Illinois and the seal thereof, this day of , ____. W. DAVID STENDEBACK, MAYOR CITY OF CARROLLTON COUNTERSIGNED: LYNN KING, CITY CLERK CITY OF CARROLLTON (SEAL) CITY OF CARROLLTON APPLICATION FOR RAFFLE LICENSE Organization Name: Address: Type of Organization: Length of Existence of Organization: If organization is incorporated, what is the date and state of incorporation? Date: State: List the organization’s presiding officer, secretary, raffle manager, and any other members responsible for the conduct and operation of the raffle. PRESIDENT: SECRETARY: Birth Date: Address: Social Security No.: Phone No.: RAFFLE MANAGER: Birth Date: Address: Social Security No.: Phone No.: List any other members responsible for the conduct and operation of the raffle on the back of this page. List name, date of birth, address, social security number, and phone number. This request is for a single raffle license. This request is for a multiple raffle license. The aggregate retail value of all prizes to be awarded: $ Maximum retail value of each prize to be awarded in the raffle: $ The maximum price charged for each raffle chance issued: The area or areas in which raffle chances will be sold or issued: Time period during which raffle chances will be issued or sold: The date, time and location at which winning chances will be determined: Date: Time: Location: If multiple raffles license is requested, list on a separate sheet, the date, time, and location for each raffle to be held within the one (1) year period of time from the date of the issuance of the license. THE APPLICATION FEES ARE NONREFUNDABLE EVEN SHOULD THE APPLICATION BE REJECTED BY THE CITY COUNCIL. CITY OF CARROLLTON APPLICATION FOR RAFFLE LICENSE SWORN STATEMENT The following officers attest to the not-for-profit character of the applicant organization. (NAME OF ORGANIZATION) Dated this day of , . PRESIDING OFFICER SECRETARY STATE OF ILLINOIS ) ) ss. COUNTY OF GREENE ) Signed and sworn to before me this day of , . PRESIDING OFFICER SECRETARY NOTARY PUBLIC CITY OF CARROLLTON SINGLE RAFFLE LICENSE License No.: Organization Name: Address: Area or areas in which raffle chances may be sold or issued: Period of time during which raffle chances may be sold: Maximum price charged for each raffle chance issued or sold: $ Date, time and location at which winning chance will be determined: Date: Time: Location: THIS LICENSE SHALL BE PROMINENTLY DISPLAYED AT THE TIME AND LOCATION OF THE DETERMINATION OF THE WINNING CHANCES. WITNESS the hand of the Mayor of the City of Carrollton and the Corporate Seal thereof, this day of , . MAYOR CITY OF CARROLLTON CITY CLERK CITY OF CARROLLTON (SEAL) CITY OF CARROLLTON MULTIPLE RAFFLE LICENSE License No.: Organization Name: Address: Area or areas in which raffle chances may be sold or issued: Period of time during which raffle chances may be sold: Maximum price charged for each raffle chance issued or sold: $ This is a license for multiple raffles to be held within the maximum period of one (1) year from date of this license. The date, time and location of each raffle is as set forth on Exhibit 1, attached hereto and hereby incorporated by reference. THIS LICENSE SHALL BE PROMINENTLY DISPLAYED AT THE TIME AND LOCATION OF THE DETERMINATION OF THE WINNING CHANCES. WITNESS the hand of the Mayor of the City of Carrollton and the Corporate Seal thereof, this day of , . MAYOR CITY OF CARROLLTON CITY CLERK CITY OF CARROLLTON (SEAL) CITY OF CARROLLTON EXHIBIT 1 The following is the date, time and location at which winning chances will be determined for multiple raffles to be held within a maximum period of one (1) year from the date of issuance of this license. Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: Date: Time: Location: CITY OF CARROLLTON POLICE DEPARTMENT APPLICANT/FIELD CHECK INFORMATION CARD Name Location Date Time Residence Address D.L.# Business Address Vehicle Color Yr. Body License Info Occupation Vehicle Modifications: Social Security Number Race Sex Height Action Leading to Check: Weight Eyes Hair Complexion Date of Birth Unusual Features: Comments: Hat Coat Associates: Cap Jacket Blouse Dress Shirt Sweater Skirt Trousers