4. QUESTIONS/ANSWERS
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Truck Stop Information
A. The Applicant verifies that it currently meets the statutory requirements to qualify for a Truck Stop establishment or Large Truck Stop establishment license, listed on the Truck Stop Affidavit. Explain your answer.
Note: The applicant must submit a Truck Stop Affidavit at the time this application is submitted to the Illinois Gaming Board.
The completed affidavit must be emailed to IGB.VG.TruckStop@illinois.gov
Fraternal or Veterans Establishments - National Headquarter Information
Name of National Fraternal or Veterans Organization
Address of National Headquarters:
City / State / Zip Code:
Date Local Charter Issued
Contact Individual at National Headquarters
Email address:
Website Address (if available):
Submit a PDF copy of the most recent letter from the Internal Revenue Service stating that the Applicant organization is either a fraternal benefit society that is exempt from federal income tax under section 501(c)(8) of the Internal Revenue Code, a domestic fraternal society that is exempt from federal income tax under section 501(c)(10) of the Internal Revenue Code, or a veterans organization that is exempt from federal income tax under section 501(c)(19) of the Internal Revenue Code.
Financial Information
A. Has the Applicant, any of its owners listed herein, or the Video Gaming Manager, been given or offered anything of value, including but not limited to a loan or financing arrangement, as an incentive or inducement to locate Video Gaming Terminals on the Applicant's premises? If yes, explain.
B. Except as otherwise disclosed in this Application and as allowed by 230 ILCS 40/25(C), does the Applicant, any of its owners listed herein, or the Video Gaming Manager have any agreements or
understandings, or an intent to enter into any agreement or understanding, with any Individual or Business Entity related to
sharing or allotting any sums of money or anything of value derived from the proposed Gaming Operation? If yes, explain.
Establishment Information
In answering questions (A) - (D) below, the distance from a proposed or existing Licensed Video Gaming Location to a preexisting
facility, riverboat, school or place of worship shall be measured by drawing a straight line between the closest part of any building used for the
proposed or existing Licensed Video Gaming Location and the closest part of any building used for the facility, riverboat, school or place of worship. When located within a
subsection of property by virtue of a lease, deed, or other arrangement (e.g., a tenant in a shopping center or commercial
condominium), measurement shall be from the subsection of property (i.e., boundaries of the proposed or existing Licensed Video Gaming Location's leased building premises).
A. Is the proposed Licensed Video Gaming Location located within 1000 feet of a preexisting facility operated by an organization licensee licensed under the Illinois Horse Racing Act of 1975 (230 ILCS 5/1 et seq.)?
B. Is the proposed Licensed Video Gaming Location located within 1000 feet of the home dock of a preexisting riverboat licensed under the Riverboat Gambling Act (230 ILCS 10/1 et seq.)?
C. Is the proposed Licensed Video Gaming Location located within 100 feet of a preexisting elementary or secondary public or private school registered with or recognized by the State Board of Education, or a place of worship incorporated under the Religious Corporation Act (805 ILCS 110/0.01 et seq.)?
D. Does the Applicant's proposed Licensed Video Gaming Location share physical space with another Video Gaming Location or applicant?
Legal, Tax, Licensing Information
A. Has the Applicant ever been convicted of a felony offense?
B. Has the Applicant ever been convicted of a crime involving dishonesty, gambling and/or moral turpitude?
C. Does the Applicant owe any past due taxes, fees or obligations to the State of Illinois?
D. Has the Applicant, any of its owners listed herein, or the Video Gaming Manager ever been involved in a Gaming business or a Gaming Operation in any state, country, or other jurisdiction? If yes, explain in detail, and provide the state or jurisdiction, date(s), the number of any license or permit issued, denied, or withdrawn, and any disciplinary action related thereto.
E. Has the Applicant, any of its owners listed herein, or the Video Gaming Manager ever facilitated, enabled, or participated in the use of coin-operated amusement devices for gambling purposes? If yes, explain.
F. If the Applicant is an Individual (Sole Proprietor), Illinois Compiled Statutes 100/10-65(c) requires applications for renewal of a license or a new license to certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying with a child support order. Failure to certify shall result in disciplinary action, and making a false statement may subject the licensee to contempt of court. Are you more than 30 days delinquent in complying with a child support order? (Note: if you are not a Sole Proprietor or not subject to a child support order, answer 'no.') If yes, explain.
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