Amusement License Application

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Please correct the field(s) marked in red below:

1
Name of Applicant (true legal business name)
 *
2
Trade Name of Business
3
Mailing Address
 *
Mailing Address
4
Address of business where tickets will be offered for sale (if different from above)
 *
Address of business where tickets will be offered for sale (if different from above)
5
Give date you began (or will begin) ticket sales at the above premises
 *
6
Last year's city amusement tax number
7
Illinois retailer occupation tax number
 *
8
Federal employer identification number
 *
9
Business Ownership (please check which one applies)
 *
Business Ownership (please check which one applies)
10
Business Information
Business Information
Application Fee: Fee is established per Ordinance 109-2016, Section 3, paragraph C & D. You will receive an email notification of required fee. Cash or check is accepted at the City Clerk's office or can be mailed to 201 E Jefferson Ave, Effingham, IL 62401.
11

Term and Conditions Agreement

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 *
12
Typed Name
 *
13
Today's Date
 *
  1. To receive a copy of your submission, please fill out your email address below and submit.