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2. 
4. ALL APPLICANTS MUST COMPLETE THE FOLLOWING FORM. THE FEE FOR ALL VENDING MACHINES/AMUSEMENT DEVICES IS $60.00 EACH.
6. Location of Machine(s)
8. Business Name*
10. Business Address*
    (City, State, Zip)
12. Business Phone*
16. Please List Location, Number and Type of Machine(s)
18. Location of Device*
    (Name of Channahon Location)
19. Address of Channahon Location*
21. Number of solid food devices
22. Number of amusement devices
24. Number of combo devices (liquid/solid)
25. Number of liquid refreshment devices
27. Number of other (specify below)
29. Device Description(s)
31. Type of Device
    (Soda, video, newspaper, snack)
32. Manufacturer Name, Number, or Other ID Markings
34. Type of Device
    (Soda, video, newspaper, snack)
35. Manufacturer Name, Number, or Other ID Markings
37. Type of Device
    (Soda, Video, Newspaper, Snack)
38. Manufacturer Name, Number, or Other ID Markings
40. Type of Device
    (Soda, Video, Newspaper, Snack)
41. Manufacturer Name, Number, or Other ID Markings
43. Type of Device
    (Soda, Video, Newspaper, Snack)
44. Manufacturer Name, Number, or Other ID Markings
48. Payment of Fee
    The fee is payable by the owner or person in control of the premises on which the machine is located.
52. 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.
54. 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.

    1. I agree.
56. Electronic Signature*
57. Date*
    Date
59. 
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field