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Vending Machine/Amusement Device License Application

  1. Village of Channahon official letterhead. Reads: Village of Channahon. Image: Channahon logo.
  2. ALL APPLICANTS MUST COMPLETE THE FOLLOWING FORM. THE FEE FOR ALL VENDING MACHINES/AMUSEMENT DEVICES IS $50.00 EACH.
  3. Location of Machine(s)
  4. (City, State, Zip)
  5. Please List Location, Number and Type of Machine(s)
  6. (Name of Channahon Location)
  7. Device Description(s)
  8. (Soda, video, newspaper, snack)
  9. (Soda, video, newspaper, snack)
  10. (Soda, Video, Newspaper, Snack)
  11. (Soda, Video, Newspaper, Snack)
  12. (Soda, Video, Newspaper, Snack)
  13. Payment of Fee
    The fee is payable by the owner or person in control of the premises on which the machine is located.
  14. The undersigned does hereby swear or affirm that the statements and information in this application are true and correct to the best of his/her knowledge and belief.
  15. 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.
  16. Village of Channahon official letterhead footer.
  17. Leave This Blank:

  18. This field is not part of the form submission.