Illinois Liquor Control Commission Pat Quinn Governor 100 W. RANDOLPH ST. SUITE 7-801 CHICAGO, ILLINOIS 60601 TELEPHONE: 312-814-2206 FAX: 312-814-2241 TDD: 312-814-1844 101 WEST JEFFERSON SUITE 3-525 SPRINGFIELD, ILLINOIS 62702 TELEPHONE: 217-782-2136 FAX: 217-524-1911 WEB SITE: www.state.il.us/LCC APPLICATION FOR STATE OF ILLINOIS B.A.S.S.E.T. LICENSE In accordance with 77 Illinois Administrative Code, Chapter XVI, Part 3500, the Illinois Liquor Control Commission is authorized to license and regulate persons who operate Beverage Alcohol Sellers and Servers Education and Training (BASSET) programs. A BASSET license will permit the licensee to conduct seller/server training of individuals provided that curriculum and testing requirements are met. Renewals will then occur on an annual basis and renewal notices will be sent 6-7 weeks in advance of license expiration. DOCUMENTS REQUIRED: A copy of training curriculum. A copy of the certificate of course completion. A copy of the pre- and post-tests given to course participants. A copy of any instrumental materials used in the course. If the applicant is a corporation, proof from the Secretary of State of Illinois that the applicant is registered to do business in Illinois and is in good standing. All applicants for licensing as a BASSET program must complete this application form. Respond to all questions on the application and furnish all required supporting documents. Failure to do so will result in the rejection of the application. BASSET LICENSE FEE $250.00 Make check or money order payable to the Illinois Liquor Control Commission. The Commission does not accept U.S. currency/cash as payment. Please print or type the information requested in the spaces provided. The application form must bear an original signature. IMPORTANT NOTICE: THE ILLINOIS LIQUOR CONTROL COMMISSION IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY UNDER THE ILLINOIS LIQUOR CONTROL ACT (235 ILCS 5/1 ET SEQ.). DISCLOSURE OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE ANY INFORMATION WILL RESULT IN THE NON-ISSUANCE OF YOUR LICENSE. FORM APPROVED BY THE STATE FORMS MANAGEMENT CENTER. IL 567-0061 (03/2006) Printed on Recycled Paper PAGE 1 OF 5 American LegalNet, Inc. www.FormsWorkflow.com FOR OFFICE USE ONLY LICENSE NO. DATE ISSUED EXPIRATION DATE COUNTER ! Application for State of Illinois BASSET License 1. APPLICANT - CORPORATE INFORMATION ! A. If you want your renewal application, your license certificate, and other ILCC correspondence sent to your “corporate” address, please check the box to the left. FEIN Enter your Federal Employer Identification Number (FEIN) or Social Security Number in this box. The FEIN is a nine-digit number issued by the U.S. Internal Revenue Service. This number is used for verification purposes only. If you do not have an FEIN number, call 1-800-829-3676 for general information on how to apply and to obtain the forms you will need. NOTE: if you have filed an application for your FEIN number, the Commission will accept your application. FEIN # or SOCIAL SECURITY NO. B. ILLINOIS BUSINESS TAX NUMBER (IBT OR SALES TAX NO.) Enter the eight-digit Illinois Department of Revenue Business Tax (Sales Tax) Number. If you are an established corporation, you must have this number in order for a license to be issued. If you need to obtain this number, call the Illinois Department of Revenue in Chicago at 312814-5258 or in Springfield at 217-785-2889. ILLINOIS BUSINESS TAX # C. TELEPHONE Enter the area code/telephone number/extension of the corporation, partnership, etc. AREA CODE/TELEPHONE NO. EXT. D. COUNTY Enter the county where the corporation, partnership, etc. is located. COUNTY E. NAME Enter the name of the sole proprietorship (assumed name), partnership, corporation (Illinois, national, or foreign), or limited liability company in this box. Note: this name must be consistent with the name printed on your Illinois Department of Revenue Sales Tax Registration Certificate. CORPORATE NAME F . DBA NAME ADDRESS Enter the street address, city, state, and Zip Code of the corporation, etc. ADDRESS IL 567-0061 (03/2006) CITY STATE ZIP CODE PAGE 2 OF 5 American LegalNet, Inc. www.FormsWorkflow.com 2. STATUS OF BUSINESS Check the applicable box (assumed name/sole proprietorship, partnership, Illinois corporation, foreign corporation, limited liability company) which corresponds to your business’ official papers filed with the Office of the Secretary of State. Based on the box that you check, provide the date of the filing of the sole proprietorship/assumed name with the county clerk; in the case of a copartnership, the date of formation of the partnership; in the case of an Illinois corporation, the date of its incorporation; in the case of a foreign corporation, the foreign state where it was incorporated and the date, as well as the date of its becoming qualified under the “Business Corporation Act of 1983” to transact business in the State of Illinois; in the case of a limited partnership, the date of formation of such partnership; or in the case of a limited liability company, the date of formation of such entity. A. B. C. D. E. ! ! ! ! ! Sole Proprietorship Partnership Illinois Corporation Foreign Corporation Limited Liability Company Date Filed With County Clerk: Date Of Formation: Date Of Incorporation: State Of Incorporation: Date Formed: Date Qualified To Do Business In Illinois: 3. OWNERSHIP INFORMATION Provide the owner/officer/partner information in accordance with the business status described under Question 2. This information must be submitted for all owners/officers/partners. The same information must be submitted for shareholders with interests equal to or exceeding 5%. The following information must be provided for each individual applicant, sole proprietor, partner, corporate officer or director (whether or not they own any stock), shareholder owning in the aggregate stock equal to or more than 5%, (including officers, directors and shareholders with stock equal to or more than 5% for all corporate shareholders), and/or manager or agent conducting the business. Indicate the total percentage of stock of the corporation, if any, which is held by persons who hold less than a 5% interest. All not-for-profit organizations and associations must provide the requested information for all corporate officers, directors and managers. If additional space is needed, provide information on a separate sheet(s) in the same format as this application requires. Before completing this section, check Question No. 6 - Eligibility. For each owner/officer/partner/5% shareholder, provide full name, home address, city, state, zip code, social security number, date of birth, sex, title/position, home telephone number, and percentage ownership. Percentage ownership should equal 100%. If there are a number of shareholders owning less than 5%, indicate the aggregate total of ownership under E. A. SOCIAL SECURITY NO. B. DATE OF BIRTH DATE OF BIRTH SEX AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. HOME ADDRESS SEX TITLE/POSITION HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. E. DATE OF BIRTH CITY HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. D. DATE OF BIRTH NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. C. HOME ADDRESS NAME (LAST, FIRST, MIDDLE INITIAL) CITY TITLE/POSITION AREA CODE/TELEPHONE NO. TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% INTEREST IL 567-0061 (03/2006) STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED % PAGE 3 OF 5 American LegalNet, Inc. www.FormsWorkflow.com 4. LISTING OF TRAINERS Provide a list of all qualified trainers who will be conducting seller/server training under this license. If additional space is needed, provide information on a separate sheet(s) in the same format as this application requires. Remember that the eligibility questions in Section 6 also apply to any person providing services under this license. A. NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. B. DATE OF BIRTH NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. IL 567-0061 (03/2006) DATE OF BIRTH SEX CITY TITLE/POSITION AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. % OWNED HOME ADDRESS SEX AREA CODE/TELEPHONE NO. HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. H. DATE OF BIRTH TITLE/POSITION HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. G . DATE OF BIRTH CITY HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. F . DATE OF BIRTH AREA CODE/TELEPHONE NO. HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. E. DATE OF BIRTH TITLE/POSITION HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. D. DATE OF BIRTH CITY HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. C. DATE OF BIRTH ZIP HOME ADDRESS CITY ZIP TITLE/POSITION AREA CODE/TELEPHONE NO. STATE % OWNED STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED STATE STATE STATE ZIP % OWNED PAGE 4 OF 5 American LegalNet, Inc. www.FormsWorkflow.com 5. ELIGIBILTY QUESTIONS These questions apply to the applicant and any other person listed under Sections 3 and 4. These questions must be answered. If the questions are not checked, the application will be rejected. If any question is checked “yes”, a written, detailed explanation is required and must be attached to this application. 6-22 ! YES ! NO HAVE YOU EVER APPLIED FOR AND BEEN DENIED A LIQUOR LICENSE? 6-23 ! YES ! NO HAVE YOU HAD ANY PREVIOUS LIQUOR LICENSE REVOKED? 6-24 ! YES ! NO HAVE YOU EVER BEEN CONVICTED OF A FELONY? 6-25 ! YES ! NO HAVE YOU EVER BEEN CONVICTED OF A GAMBLING OFFENSE AS DEFINED UNDER SECTION 5/6-2 OF THE ACT WHICH INCLUDES OFFENSES ENUMERATED IN 720 ILCS 5/28-1(a)1-11, “GAMBLING;” 720 ILCS 5/28-1.1(a)-(d) “SYNDICATED GAMBLING;” AND 720 ILCS 5/28-3 “KEEPING A GAMBLING PLACE”? 6-25 ! YES ! NO IF OPERATING AS A SOLE PROPRIETORSHIP OR A PARTNERSHIP, ARE YOU OR YOUR PARTNER(S) CURRENTLY NOT CITIZENS OF THE UNITED STATES OR RESIDENT ALIENS WITH LEGAL STATUS? 6-28 ! YES ! NO HAVE YOU RECEIVED OR BORROWED MONEY OR ANYTHING OF VALUE DIRECTLY OR INDIRECTLY FROM ANY OTHER LICENSEES, REPRESENTATIVES OF A LICENSEE, OR SUPPLIERS OF ALCOHOLIC PRODUCTS? 6. SIGNATURE/TITLE/DATE Please sign and date the application form and provide your title with the organization. The application must be signed by an owner, an officer, a partner or an officially authorized agent of the business. The signature must be an original, rubber stamps are not accepted. I, THE UNDERSIGNED APPLICANT OR AUTHORIZED AGENT THEREOF, SWEAR OR AFFIRM THAT: THE MATTERS STATED IN THE FOREGOING APPLICATION ARE TRUE AND CORRECT; THEY ARE MADE UPON MY PERSONAL KNOWLEDGE AND INFORMATION; THEY ARE MADE FOR THE PURPOSE OF REQUESTING THE STATE OF ILLINOIS TO ISSUE THE LICENSE HEREIN APPLIED FOR; THE APPLICANT IS QUALIFIED AND ELIGIBLE TO OBTAIN THE LICENSE APPLIED FOR; AND THE APPLICANT WILL NOT VIOLATE ANY OF THE LAWS OF THE UNITED STATES OF AMERICA OR THE STATE OF ILLINOIS, IN PARTICULAR, THE ILLINOIS LIQUOR CONTROL ACT, RULES AND REGULATIONS, AND THE CIVIL RIGHTS SECTIONS THEREOF. Further, I agree to notify this Commission within 30 working days of changes in any of the above information SIGNATURE OF APPLICANT/AUTHORIZED AGENT IL 567-0061 (03/2006) TITLE/POSITION DATE PAGE 5 OF 5 American LegalNet, Inc. www.FormsWorkflow.com