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8990 Lyons Street, Hodgkins, IL 60525

Vending Sticker Application

Date of Application

Vending Company Name *

Address *

City *

State *

Zip Code *

Phone Number *

Email Address

Machine Location

Company Name *

Address *

City *

State *

Zip Code *

Phone Number *

Type(s) of vending machine being applied for *

Amusement Device or Electronic Game ($50)

Juke Box or other Musical Device ($50)

Cigarette & Tobacco Machine ($50)

Candy/Soft Drink/Food/Coffee/Ice Cream/Snack Machines ($25)

Any vending machine not listed above ($25)

IT IS YOUR RESPONSIBILITY TO DISPLAY VENDING STICKERS. IF YOUR COMPANY DOES NOT OWN THE VENDING MACHINE YOU SHOULD NOTIFY YOUR VENDER TO PURCHASE A VENDING STICKER AND FORWARD THIS FORM TO THEM

List type(s) of the machines being applied for:

List type(s) of the machines being applied for:

e.g. food, soda, ice cream, etc. If it is a gaming machine please list the name of game(s) e.g. crazy taxi, super ski, poker etc.