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2. Coin Operated Amusement Device Center Restaurant Application Form - New
6. Fee Schedule

   Annual license fee:  $500.00

   License fee per Amusement Device:  $75.00

   *The above fees are in addition to any other required business licensing fees.  Annual fee will be due once license is approved and annually thereafter prior to the annual license expiration date of January 31st.

8. This application must be accompanied by an application for a business license.*

   1. I have already submitted a business license.
   2. I have not yet submitted a business license.
10. Corporate Name/Sole Propietor*
11. Assumed Business Name/DBA*
13. Business Address in Hanover Park*
14. Business Phone Number*
16. FEIN Number or SSN if Sole Proprietor*
18. Days of Operation*

    1. Sunday
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
    7. Saturday
19. Hours of Operation*
    Hours of Operation Start Time

    —

    Hours of Operation End Time
23. Provide a Listing Identifying Each Amusement Device to be Licensed*
25. Owner of the Amusement Devices

    1. Business Owner
    2. Other Party
27. Name of Device Owner*
29. Personal Address of Device Owner*
31. City*
32. State*
33. ZIP Code*
35. Device Owner Email Address*
36. Phone*
40. No False statements
    Your submission of this form certifies that the information provided is true and correct.
42. Execute*

    1. I agree

    By selecting I agree option below you are giving your electronic signature.
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit Submit and Print

* indicates a required field