Illinois State Seal
Illinois Gaming Board  
Video Gaming Location License Application  


5. VERIFICATION

Undersigned, the duly authorized agent of the Applicant, its owners and the Video Gaming Manager identified in this Application, swears and certifies under penalty of law that all answers and information provided in this Application and associated documents are true, correct and complete to the Best of my Knowledge after substantial inquiry. Applicant acknowledges that any misrepresentation, failure to reveal information or omission is grounds for denial of a license and/or revocation of any license for which this Application is submitted. Applicant is under a continuing duty to disclose promptly any changes in the information provided in the Application and additional information and materials submitted to the Illinois Gaming Board (“Board”). The duty to make such additional disclosures shall continue throughout any period of licensure granted by the Board.

I, the duly authorized agent of the Applicant, its owners and the Video Gaming Manager identified in this Application, have read this Verification and understand its terms. On behalf of and in accordance with the instructions of the Applicant and its owners identified in this Application, I execute this Verification with full knowledge that they will be bound hereby.

Authorized agent completing this form:
Office/relationship to Applicant: