City of East Peoria APPLICATION FOR CITY OF EAST PEORIA RETAILER S LIQUOR LICENSE

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City of East Peoria APPLICATION FOR CITY OF EAST PEORIA RETAILER S LIQUOR LICENSE Liquor Control Commission: David W. Mingus Gary Densberger Timothy Jeffers 100 S.

1 City of East Peoria APPLICATION FOR CITY OF EAST PEORIA RETAILER S LIQUOR LICENSE Liquor Control Commission: David W. Mingus Gary Densberger Timothy Jeffers 100 S. Main Street East Peoria, Illinois Telephone: (309) Fax: (309) Website: All applicants for licensing as a liquor retailer must complete this application form. Respond to all questions on the application and furnish all required supporting documents. Failure to do so may result in the rejection of the application and non-issuance of the City of East Peoria Retailer s Liquor License. LIQUOR LICENSE APPLICATION FEE $250.00

2 CITY OF EAST PEORIA LIQUOR LICENSE APPLICATION CLASS OF LICENSE APPLIED FOR: DATE PART 1 (To be completed by all applicants) NAME OF APPLICANT ADDRESS OF APPLICANT PHONE NO. ( ) STATE THE TYPE OF BUSINESS OWNERSHIP APPLICABLE TO THIS LICENSE APPLICATION ( ) SOLE OWNER ( ) PARTNERSHIP ( ) CORPORATION ( ) CLUB STATE THE APPLICANT S FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) PART 2 (To be completed by all applicants) LOCATION OF OR PROPOSED LOCATION OF LICENSED PREMISES NAME OR PROPOSED NAME OF LICENSED PREMISES DO YOU OWN THE PROPERTY? ARE YOU LEASING OR PURCHASING THE PROPERTY WHERE THE LICENSED PREMISES ARE LOCATED? IF YOU ARE RENTING OR LEASING, STATE THE NAME AND ADDRESS OF THE LANDLORD DATE OF LEASE TERMINATION OF LEASE A current copy of the lease must be submitted with this application. List the name, address and phone number of at least three credit references and identify the name of the person or entity in whose name the credit exists.

3 PART 3 (To be completed by partnership, corporation or club applicants only. If sole owner applicant, skip to Part 4) STATE THE FULL NAME OF THE CORPORATION, PARTNERSHIP OR CLUB STATE THE DATE OF INCORPORATION OF FORMATION STATE THE OBJECT FOR WHICH THE PARTNERSHIP, CORPORATION OR CLUB WAS ORGANIZED HAS THIS PARTNERSHIP, CORPORATION OR CLUB EVER APPLIED FOR A LIQUOR LICENSE IN THIS OR ANY OTHER CITY? IF SO, WHERE? WHEN? DISPOSITION OF APPLICATION HAS THIS PARTNERSHIP, CORPORATION OR CLUB EVER HAD A LIQUOR LICENSE ISSUED IN ILLINOIS OR ANY STATE OR CITY REVOKED OR SUSPENDED? GIVE THE REASON FOR THE SUSPENSION OR REVOCATION IF THE BUSINESS IS TO BE OPERATED UNDER AN ASSUMED NAME, STATE THE NAME TO BE USED IF SO, STATE THE DATE ON WHICH THE ASSUMED NAME WAS REGISTERED WITH THE TAZEWELL COUNTY CLERK STATE THE NAME AND ADDRESS OF EACH PERSON OR ENTITY OWNING 5% OR MORE OF THE STOCK OF THE CORPORATION; OR IF A PARTNERSHIP APPLICANT, THE NAME AND ADDRESS OF EACH GENERAL PARTNER OR LIMITED PARTNER, OWNING MORE THAN 5% OF THE AGGREGATE LIMITED PARTNERSHIP INTEREST (EACH PERSON LISTED MUST COMPLETE A SEPARATE PART 4 OF THIS APPLICATION) STATE THE NAME, ADDRESS AND TITLE OF EACH OF THE DIRECTORS OF THE CORPORATION OR CLUB (EACH PERSON LISTED MUST COMPLETE A SEPARATE PART 4 OF THIS APPLICATION)

4 STATE THE NAME, ADDRESS AND TITLE OF EACH OF THE OFFICERS OF THE CORPORATION OR CLUB (EACH PERSON LISTED MUST COMPLETE A SEPARATE PART 4 OF THIS APPLICATION) STATE THE NAME AND ADDRESS OF EACH MANAGER OR ASSISTANT MANAGER WHO WILL MANAGE THE DAY TO DAY OPERATIONS OF THE LICENSED PREMISES (EACH PERSON IDENTIFIED MUST COMPLETE PART 4 OF THIS APPLICATION)

5 PART 4 (To be completed by a single individual for sole owner applicants. For all other applicants (partnerships, corporations and clubs) this section must be completed by each of the individuals identified in Part 3.) NOTE: Additional copies of Part 4 are available upon request from the City Clerk or additional copies may be made of this application. NAME Last First M.I. Social Security Number ADDRESS DATE OF BIRTH PLACE OF BIRTH AGE HEIGHT WEIGHT HAIR EYES SPOUSE S NAME MAIDEN NAME (IF APPLICABLE) ARE YOU EMPLOYED? IF SO, STATE YOUR PRESENT OCCUPATION STATE THE NAME, ADDRESS AND PHONE NUMBER OF YOUR PRESENT EMPLOYER ARE YOU A PUBLIC OFFICIAL? IF SO, GIVE FULL DETAILS OF THE POSITION HELD DO YOU RENT OR OWN YOUR RESIDENCE? IF RENTAL, NAME AND ADDRESS OF LANDLORD HOW LONG AT PRESENT ADDRESS? IF LESS THAN ONE YEAR, PRIOR ADDRESS NAME, AGE AND RELATIONSHIP OF ALL PERSONS LIVING WITH YOU NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU HOW LONG HAVE YOU BEEN A RESIDENT OF THE CITY OF EAST PEORIA? ARE YOU A CITIZEN OF THE UNITED STATES? IF A NATURALIZED CITIZEN, GIVE DATE OF NATURALIZATION HAVE YOU EVER BEEN CONVICTED OF A FELONY OR ANY GAMBLING OR PROSTITUTION RELATED OFFENSE? IF SO, GIVE DATE, LOCATION, CHARGE AND DISPOSITION OF CASE

6 HAVE YOU EVER FILED A PETITION IN BANKRUPTCY? IF SO, GIVE DATE AND COURT WHERE FILED. DO YOU OWN AN AUTOMOBILE? IF SO, GIVE MAKE, MODEL AND LICENSE NUMBER STATE YOUR EMPLOYMENT RECORD FOR THE PAST TEN (10) YEARS GIVING EMPLOYER S NAME, ADDRESS, POSITION, DATES OF EMPLOYMENT AND REASON FOR LEAVING. EMPLOYER S NAME AND ADDRESS POSITION HELD DATES OF EMPLOYMENT REASON FOR LEAVING IF YOU HAVE LIVED AT YOUR PRESENT RESIDENCE FOR LESS THAN TEN (10) HEARS, STATE THE ADDRESS OF EACH RESIDENCE YOU HAVE LIVED AT IN THE PAST TEN (10) YEARS. HAVE YOU EVER APPLIED FOR A LIQUOR LICENSE PREVIOUSLY IN THIS OR ANY OTHER CITY? IS SO, WHERE? WHEN? DISPOSITION OF APPLICATION HAVE YOU EVER HAD AN OWNERSHIP INTEREST (STOCKHOLDER, PARTNER) IN ANY BUSINESS ENTITY THAT HAS APPLIED FOR A LIQUOR LICENSE IN THIS OR ANY OTHER CITY? IF SO, STATE THE NAME OF THE BUSINESS WHERE LOCATED IS THE LICENSE STILL VALID? IF NOT, STATE THE REASON WHY THE LICENSE IS NOT VALID IF THE LICENSE IS STILL VALID, STATE THE AMOUNT OF YOUR OWNERSHIP INTEREST DO YOU POSSESS A CURRENT FEDERAL WAGERING STAMP? IF SO, GIVE THE REASONS THEREFORE HAVE YOU EVER POSSESSED A FEDERAL WAGERING STAMP? IF SO, WHEN?

7 LIST THE NAME, ADDRESS AND PHONE NUMBER OF FIVE (5) CHARACTER REFERENCES OTHER THAN RELATIVES. THESE PERSONS MAY BE CONTACTED WITH REGARD TO YOUR QUALIFICATIONS TO HOLD A LIQUOR LICENSE IN THE CITY OF EAST PEORIA. I have carefully read the Illinois Liquor Control Act and Chapter 3 of the East Peoria City Code. I understand that it is my responsibility to remain familiar with all state and local liquor control regulations as modified from time to time. I understand that the license applied for may be revoked for any violation of a state or local regulation, including but not limited to, sale of alcohol to a minor, failure to report an altercation, or sale to an intoxicated person. Signature STATE OF ILLINOIS ) ) SS COUNTY OF ) I, the undersigned, a Notary Public in and for the County and State aforesaid, do hereby certify that the person whose signature appears above, appeared before me in person and being sworn on oath, stated that the information hereinabove given was the truth. Dated this day of, 20. Notary Public Commission expires

8 I hereby certify that to the best of my knowledge, all statements made herein are truthful and accurate. Signature of Applicant (If a corporation, give the title of the person signing the application.) STATE OF ILLINOIS ) ) SS COUNTY OF ) I, the undersigned, a Notary Public in and for the County and State aforesaid, do hereby certify that the person whose signature appears above, appeared before me in person and being sworn on oath, stated that the information hereinabove given was the truth. Dated this day of, 20 Commission expires: Applicant was fingerprinted: and photographed Processed Completed East Peoria Police Department

9 TO THE COUNCIL OF THE Application and Bond for Liquor, Malt and Vinous Beverage License CITY OF EAST PEORIA STATE OF ILLINOIS APPLICATION Your petitioner respectfully petitions you to grant Vinous Beverages, located at Illinois, from May 1, 20 to April 30,20 a Liquor License to operate an Establishment for the purpose of selling Liquor, Malt and, in the City of East Peoria, State of Your petitioner states that a citizen of the United States, and resident of this City for one continuous year, and that he has never been convicted of felony; that the proposed location is not within 100 feet of any church, school, hospital, home for aged or indigent persons or veterans, their wives or children, or any military or naval station. The applicant further agrees to operate the aforesaid place of business in accordance with the laws of the State of Illinois and the ordinances of the City of East Peoria, Illinois, which he has read and is well acquainted with. Applicant further represents the owner or lessee of the premises above, and if lessee, shall attach a copy of the lease showing a term in excess of the period for which license is issued. In pursuance of the ordinances now in force and effect, your petitioner respectfully submits the hereunto attached bond, signed by your petitioner as principal and by as sureties, all of the County of Tazewell, in the State of Illinois, and conditioned upon the faithful observance of the conditions herein contained. Dated x...applicant State of Illinois County of Tazewell }ss Subscribed and sworn to before me, this...day of (SEAL)... Notary Public BOND KNOW ALL MEN BY THESE PRESENTS, that we......as principal, and......as sureties, being property holders in the County of Tazewell, and State of Illinois, are held and firmly bound unto the City of East Peoria in the penal sum of FIVE HUNDRED ($500.00) DOLLARS, lawful money of the United States, for the payment of which well and truly to be made, we bind ourselves, and each of us our heirs, executors and administrators, and each of them, jointly, severally and firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH, that, if the above bounden......who has filed his application for a Class...Liquor, Malt and Vinous Beverage License in the City of East Peoria, does operate his Alcoholic Beverage Business in accordance with the police regulations and ordinances now in force or effect or which hereafter may be enacted in that respect in the City of East Peoria this obligation shall be void; otherwise to remain in force and effect. WITNESS our hands and seals this...day of... A. D STATE OF ILLINOIS, County of Tazewell }ss Principal... (SEAL)... (SEAL) Sureties... (SEAL) Sureties... (SEAL) I,..., a Notary Public in and for the Said County and State, do hereby certify that..., as principal, and..., as sureties, personally known to me to be the same persons whose names are subscribed to the foregoing instrument, appeared before me this day in person and acknowledged that they signed and sealed said instrument as their free and voluntary act, for the uses and purposes therein set forth. Given under my hand and...seal, this...day of...a.d (SEAL)... Notary Public

10 Checklist for Liquor Licenses In an effort to ensure that all liquor license applications are processed in a timely manner, the following checklist has been provided. Liquor License Application (Parts 1 and 2 must be completed by all applicants, Part 3 must be completed by partnership, corporation, LLC or club applicants only, and Part 4 must be completed by each partner, directors and officers of the corporation, LLC or club and each manager or assistant manager of the licensed premise; Background investigation completed on every person completing Part 4 and $ application fee payable to the City of East Peoria and $39.25 per person payable to the Illinois State Police Department for investigation fee; A copy of the current lease/purchase agreement; A Financial Statement; A copy of Dram Shop Liability Insurance; A copy of the Articles of Incorporation ; and A certificate of bond in the sum of $500 to the city as oblige. It is the responsibility of the liquor license holder to be aware of all state and local liquor control regulations. If there is a change in stockholders/corporation directors/officers or manager, the City must be notified and the person(s) must complete Part 4 of the application and a background investigation must be completed. All licenses issued shall be considered a personal privilege and no license may be transferred to or used by any other person(s).

1050 W ROMEO RD ROMEOVILLE, IL (815) FAX: (815) APPLICATION FOR LIQUOR LICENSE

1050 W ROMEO RD ROMEOVILLE, IL 60446 (815) 886-7200 FAX: (815) 886-2762 APPLICATION FOR LIQUOR LICENSE The undersigned hereby makes (make) application for the issuance of a city retailer s license for