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2. Vendor License Application Form - New
6. Business Information *

   Provide local business & corporate information

   1. Incorporated- Secretary of State
   2. Sole Proprietor- County
7. Corporate Name/ Sole Propietor*
8. Assumed Business Name/DBA*
10. IBT No./Retailer's Occupational Tax No. *
11. FEIN Number*
15. Vendor Activity - Select one or more of the following activities associated with your business.*

    1. Food/Beverage Vending Vehicle
    2. Billiards / Pool Tables
    3. Vending Machines
    4. Amusement Devices

    1. Automatic Music Devices
    2. Coin-Operated Amusement
    3. Private Outdoor Pay Telephone
17. Number of Vehicles
18. Food Vending Vehicle Location

    Upload a map showing the location the food vending vehicle will be parked.

20. Which County will the Vehicle(s) Serve?

    1. Cook
    2. DuPage
    3. Both
21. A Food Service Permit must be obtained from DuPage County's Health Department before this vendor license will be issued

    1. I have already obtained my county permit
    2. I have an application pending with the county
    3. I am aware of this requirement and will obtain a food service license from the county
23. A Food Service Inspection must be completed by the Village's contracted Health Inspector before this vendor license will be issued

    1. I have already been inspected and approved
    2. I understand this requirement
25. Food Service Inspection Report

    Upload a copy of your approved food service inspection report

26. Upload Menu

    Upload a copy of your menu for review

28. Food/Beverage Vending Vehicle Duration

    How long will the vehicle be in use?

    1. Single day, one-time event
    2. Multiple-day, one-time event
    3. Regularly, but not daily
    4. Daily
29. Days of Operation

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

    —

    Hours of Operation End Time
32. Billiards - Number of Tables
33. Vending Machine - Type
    -- Select One --CigaretteFoodBoth
34. Number of Cigarette Machines
35. Number of Food Machines
37. Number of Amusement Devices
38. Number of Automatic Music Devices
39. Coin-Operated Devices - Number of Machines
40. Pay Phone - Number of Phones
42. Type of Amusement Devices

    Describe the type of amusement devices

44. Provide a full listing of each machine type with its serial number*

    Example:  Soda Machine 1 - CC123456

46. I certify that the number of vehicles/machines listed is accurate to the best of my knowledge. I understand that inaccurate reporting may result in penalty fees.
    -- Select One --Yes - I have verified the information provided is accurate.
50. Preffered Mailing Address*

    1. Vehicle/Machine Owner Address
    2. Vehicle/Machine Location Address
52. Machine Ownership – Principals, Sole Owners, Shareholders, Partners, etc.

    If you have additional, please attach the listing.

54. Vehicle/Machine Owner*
55. Email Address*
57. Address*
59. City*
60. State*
61. Zip Code*
63. Phone Number*
67. Machine Location

    Building/Property Owner

69. Building/Property Owner*
70. Email Address
72. Address*
74. City*
75. State*
76. Zip Code*
78. Phone Number*
80. Execute*

    1. I agree

    By selecting I agree option below you are giving your electronic signature.
81. No False statements
    Your submission of this form certifies that the information provided is true and correct.
83. Name*

    Information for individual completing this form.

84. Title*
86. Phone Number*
87. Email Address*
Leave This Blank:


89. 1. Receive an email copy of this form.
90. Email address

    This field is not part of the form submission.

91. Submit Submit and Print

* indicates a required field