Business Registration

Business Information

Business Name	Richmond Quik Shop (GEI-118)
Business Street Address (Including Unit or Suite, if applicable)	---
Mailing Address (If different than business street address above)	750 Bunker Ct Ste 100, Vernon Hills IL 60061-1864
Business Phone	+18156786139
Email Address	---
Would you like to sign up for the Village E-Blast for current events and information?	---
Website Address	---

Business Owner Information

Business Owner(s) Name	---
Business Owner(s) Home Address	---
Business Owner(s) Phone Number (Home or Cellphone)	---

Is This A New Business?

Is This A New Business?

No, my business was registered under the same name prior to May 1st of this year.

Other Important Information

Illinois Sales and Use Tax and/or Retailers Occupation Tax	---
Operating Days	Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday
Operating Hours	Monday thru Saturday: 5:00 am to midnight Sunday: 6:00 am to midnight
Number of Shifts	3
Number of Employees	5
Nature of Business	gas station/convenience store

Fueling Stations

Does your business have fueling stations on site?

Yes

Hoses

Number of gas hoses

12

Police Required Information

Burglar Alarm	Yes
Fire Alarm	No
Hazardous Materials	Yes

Burglar Alarm

Please Provide Additional Information	---
Monitoring Agency	---
Monitoring Agency Telephone Number	---
Alarm Type	---

Hazardous Materials

Provide Detail Information

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Emergency Contacts: Please provide 3 names/phone numbers of key holders who are available 24 hours in case of an emergency.

1) Name	Shannon Delgado
1) Phone Number	+18478509030
2) Name	Matthew Loiacano
2) Phone Number	+12243028900
2) Alternate Phone Number
3) Name	Harold DuBose
3) Phone Number	+12247751690

Late Fees

Was this submitted after May 22?

No

Prorated Fees

Was this submitted between August 1 - October 31?	No
Was this submitted between November 1 - January 31?	No
Was this submitted After February 1?	No

Certification Number

Certificate No

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