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 W. JEFFERSON ST. 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 NON-RESIDENT DEALER’S LIQUOR LICENSE DEFINITIONS A Non-resident Dealer’s license shall permit such licensee to ship into and warehouse alcoholic liquor in this State from any point outside of this State, and to sell such alcoholic liquor to Illinois-licensed foreign importers and importing distributors and to no one else in this State; provided that said Non-resident Dealer shall register with the Illinois Liquor Control Commission each and every brand of alcoholic liquor which it proposes to sell to Illinois licensees during the license period; and further provided that it shall comply with all of the provisions of Section 6-9 of the Liquor Control Act with respect to registration of such Illinois licensees as may be granted the right to sell such brands at wholesale. Please note that you must appoint an Illinois-licensed distributor (see page 3). If you have agents, representatives or persons acting on your behalf in Illinois that sell or discuss pricing terms of alcoholic liquor you are required to register each of these individuals by submitting forms IL 567-0053 “Application for Registration - Manufacturer’s Registered Agent”, and IL 567-0054 “Statement of Representation - Registration of Manufacturer’s Agent”. Currently licensed Illinois manufacturer - Class 1- Distiller, Class 2- Rectifier, or Class 3-Brewer. Non-resident dealer who is a manufacturer of less than 500,000 gallons per year combined plant total, or agent thereof AND/OR Primary U.S. Importer exporting less than 500,000 gallons into Illinois yearly, or agent thereof. Non-resident dealer who is a manufacturer of 500,000 gallons or more per year combined plant total, or agent thereof AND/OR primary U.S. importer exporting 500,000 gallons or more into Illinois yearly, or agent thereof. FEE: NONE FEE: $90.00 FEE: $270.00 Please include the following REQUIRED supporting documents: • The enclosed Registration Statement; • The following U.S. Department of the Treasury Tax and Trade Bureau applicaton forms (please visit the TTB website at www.ttb.gov or call 1-877-882-3277 or for further information regarding these forms): a) A copy of the Label Approval. Visit www.ttb.gov to download the F 5100.31 application form; b) A copy of the Basic Permit. Visit www.ttb.gov to download the F 5100.24 application form; • The enclosed Schedule L (RL-26-L) from the Illinois Department of Revenue (please call IDOR at 217-785-2622 should you require further assistance); • The enclosed Application for Registration – Manufacturer’s Registered Agent (if applicable*); • The enclosed Statement of Representation – Registration of Manufacturer’s Agent (if applicable*). *If you have agents, representatives or persons acting on your behalf in Illinois that sell or discuss pricing terms of alcoholic liquor, you are required to register each of these individuals by submitting the above two forms. 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 567-0059 (03/2006) Printed on Recycled Paper Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com FOR OFFICE USE ONLY LICENSE NO. ILLINOIS BUSINESS TAX # (DO NOT FILL IN SPACE BELOW) DATE ISSUED EXPIRATION DATE Application for State of Illinois Non-resident Dealer’s Liquor License A. CORPORATE/BUSINESS(DBA) INFORMATION 1. FEIN Enter your Federal Employer Identification Number (FEIN) 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 # 2. PHONE NUMBER Enter the telephone number for the corporation, partnership, etc. AREA CODE/TELEPHONE NUMBER EXT. 3. CORPORATE NAME (Also list trade or business name, if different from corporate name) Enter the name of the corporation (Illinois, national, or foreign), partnership or limited liability company in this box. CORPORATE NAME DBA NAME 4. CHIEF OPERATING ADDRESS Enter the street address, city, state, and Zip Code of the corporation, partnership, etc.. ADDRESS CITY STATE ZIP CODE 5. CONTACT PERSON List the name and address of the person upon whom all “Service of Process” shall be made on behalf of the applicant and to be contacted in the event of any other problems or questions (person need not be an Illinois resident). NAME ADDRESS IL 567-0059 (03/2006) CITY Printed on Recycled Paper STATE ZIP CODE Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com B. APPLICANT INFORMATION 6. Applicant is the: Actual Manufacturer of the products described herein. Primary United States importer of products described herein which are manufactured outside of the United States (Provide an appointment letter from the manufacturer). Duly registered agent of the manufacturer or duly registered agent of the primary U.S. importer of products described herein. (Provide an appointment letter from the manufacturer). (a) List, alphabetically, on separate sheet and attach, all of the alcoholic beverage products for distribution in Illinois, which you manufacture, by their full product name as shown on their federally (BATF)approved labels. (b) 7. If you are not the actual manufacturer of any given alcoholic beverage product(s) which you distribute for sale within Illinois, list alphabetically, by manufacturer on a separate sheet, all of the alcoholic beverage products which you distribute as primary United States importer or duly registered agent. NOTE: THE ANSWERS TO QUESTIONS 7(a) AND 7(b) DO NOT FULFILL THE SEPARATE REGISTRATION REQUIREMENTS SET FORTH IN SECTION 5/6-9 OF THE ACT AND SECTION 100.60 OF THE RULES OF THE COMMISSION. THE SAME ARE TO BE REPORTED ON THE REGISTRATION FORM OF THIS COMMISSION. PRODUCTS NOT SO REGISTERED MAY NOT BE DISTRIBUTED IN ILLINOIS EVEN IF A NON-RESIDENT DEALER’S LICENSE IS SECURED. CHANGES IN PRODUCTS LISTED ON THIS FORM AND ON THE REGISTRATION FORM MUST BE MADE PRIOR TO SHIPMENT OF PRODUCTS INTO ILLINOIS. 8. Have all Registration Statements required by Section 5/6-9 of the Act and Section 100.60 of the Rules of the Commission been filed Yes No by the person who owns or controls the brands listed above? 9. Has a pre-approved copy of the “BATF Application for Label Approval” been filed for each and every product listed in your answer to Question #7 and on your Registration Statement(s)? Yes No 10. List the name(s) and address(es) of all Illinois distributors who are currently registered under Section 5/6-9 to distribute these products. (Attach a separate sheet if needed) ADDRESS OF ILLINOIS DISTRIBUTOR NAME OF ILLINOIS DISTRIBUTOR 11. Is the Applicant currently licensed in any capacity, other than a Non-resident Dealer, by this Commission? If yes, give name of licensee and current State liquor license no. NAME Yes No CURRENT ILLINOIS LIQUOR LICENSE NO. 12. Is any subsidiary, affiliate, officer, associate, member, partner, representative, employee, agent, shareholder of the applicant OR the manufacturer for whom you act as primary United States importer or agent OR is the manufacturer itself currently licensed in any capacity, other than a Non-resident Dealer, by this Commission? Yes If yes, give name(s) of licensee(s) and No current State liquor license no.(s). (Attach additional sheet(s), if necessary) NAME CURRENT ILLINOIS LIQUOR LICENSE NO. NAME CURRENT ILLINOIS LIQUOR LICENSE NO. IL 567-0059 (03/2006) Printed on Recycled Paper Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com B. APPLICANT INFO ( cont’d.) 13. If applicant warehouses liquor in Illinois, give address ADDRESS 14. CITY STATE ZIP CODE COUNTY Name/Title/Phone No. of person completing this application. NAME TELEPHONE NO. TITLE C. OWNERSHIP INFORMATION For each owner/officer/partner/5% or greater shareholder, provide the following: 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 d. below: a. NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. b. DATE OF BIRTH NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. DATE OF BIRTH SEX TITLE/POSITION AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. HOME ADDRESS SEX CITY HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. c. DATE OF BIRTH HOME ADDRESS CITY TITLE/POSITION AREA CODE/TELEPHONE NO. d. TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% INTEREST STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED % AFFIDAVIT The above information is supplied for the purpose of inducing the Illinois Liquor Control Commission to issue a Nonresident Dealer’s license to the applicant herein and is true and correct, and made upon my personal knowledge and information. I further swear or affirm that 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. Signature of Applicant or Authorized Agent Signature of Applicant or Authorized Agent Title or Position Title or Position Date Signed Date Signed NOTE: If the license is to be issued to a partnership, two partners must sign. If the license is to be issued to a corporation, the president and secretary of the corporation must sign, or duly authorized corporate representative. IL 567-0059 (03/2006) Printed on Recycled Paper Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com Registration Statement (Illinois Compiled Statutes, Chapter 235) TO THE ILLINOIS LIQUOR CONTROL COMMISSION Pursuant to the requirement of Section 5/6-9 of the Illinois Liquor Control Act the undersigned, a (Insert -- Manufacturer, Distributor, Importing Distributor, or Non-resident Dealer) does hereby register with said Commission the following named persons or companies as being the only ones to whom the undersigned has granted the right to sell or distribute at wholesale within the State of Illinois, one or more of those alcoholic liquors which bear trade-marks, brands or names owned or controlled by the undersigned. The undersigned does hereby further register opposite the name of said persons or companies, the respective trademarks, brands or names, owned or controlled by the undersigned, concerning which said persons have been given such distributing rights and the rspective geographical territories for which such distributing rights have been given to said persons or companies, and the period of time for which such rights are granted to such person. NAME, ADDRESS, CITY, STATE AND ZIP CODE OF WHOLESALER TRADE-MARK BRAND, OR NAME OF ITEM TIME PERIOD GEOGRAPHICAL TERRITORY CORPORATE NAME: IMPORTANT NOTICE This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the Illinois Liquor Control Act, Ch. 235, Ill. Comp. Stat., 5/6-9. Disclosure of this information is MANDATORY. Failure to provide any information will result in nonissuance of your license and/or nonregistration of your products. This form has been approved by the Forms Management Center. ADDRESS: (City or Town) SIGNED BY: (Title) DATE: STATE LICENSE # IL 567-0014 (01/2006) (Street Number) EXP. DATE Printed on Recycled Paper American LegalNet, Inc. www.FormsWorkflow.com Illinois Department of Revenue RL-26-L Page ____ of ____ Schedule L Out-of-state Sellers’ Shipment Report Read this information first Make a copy of this schedule before completion if you need to report more than provided for here. After you have completed your schedule(s), make a photocopy and retain the copy for your records. Step 1: Identify your business and your type of transaction a Name:_______________________________________________ Illinois Business Tax number (IBT no.): __ __ __ __ __ __ __ __ Address:_____________________________________________ Federal Employer Identification number: ____ _______________ Number and street (FEIN) Tax period: __ __ __ __ __ __ __________________________________________________ City State/Providence ZIP Month Country/Territory:___________________________ b Year Telephone: ______________________ Ext: __________ Check here if you had no shipments to report during this tax period. Step 2: Tell us about the alcoholic liquors you shipped into Illinois Equivalent in wine gallons Invoice no. Account no. of and date whom you sold and shipped to Name and complete address of whom you sold and shipped to Cider 0.5 % Alcohol 14 % Alcohol > 14% Alcohol 20% to 7% or beer or less and < 20% or more ____________ ___________ ______________________________________________ __________ __________ __________ __________ ________ ______________________________________________ ______________________________________________ ____________ ___________ ______________________________________________ __________ __________ __________ __________ _ _/_ _/_ _ _ _ ______________________________________________ ______________________________________________ ____________ ___________ ______________________________________________ __________ __________ __________ __________ _ _/_ _/_ _ _ _ ______________________________________________ ______________________________________________ ____________ ___________ ______________________________________________ __________ __________ __________ __________ _ _/_ _/_ _ _ _ ______________________________________________ ______________________________________________ ____________ ___________ ______________________________________________ __________ __________ __________ __________ _ _/_ _/_ _ _ _ ______________________________________________ ______________________________________________ ____________ ___________ ______________________________________________ __________ __________ __________ __________ _ _/_ _/_ _ _ _ ______________________________________________ ______________________________________________ ____________ ___________ ______________________________________________ __________ __________ __________ __________ _ _/_ _/_ _ _ _ ______________________________________________ ______________________________________________ Page subtotal RL-26-L (R-04/06) IL-492-1493 _________ __________ _________ _________ Grand total _________ __________ _________ _________ (See instructions.) American LegalNet, Inc. www.FormsWorkflow.com Schedule L Instructions General Information Who must file this schedule? You must file Schedule L, Out-of-state Sellers’ Shipment Report, if you are a seller located outside of Illinois and make shipments of alcoholic liquors into Illinois. When and where do I file Schedule L? You must file Schedule L on or before the fifteenth day of each month for the preceding month. Note: You must file Schedule L even if you made no shipments during the reporting period. Mail your completed schedule to LIQUOR AND CIGARETTE TAX SECTION ILLINOIS DEPARTMENT OF REVENUE PO BOX 19477 SPRINGFIELD IL 62794-9477 Step-by-Step Instructions Step 1: Identify your business and type of transaction a Write your business’ name, address, and Illinois Business Tax number (IBT no.) that has been issued to you by us. Also, tell us your Federal Employer Identification number (FEIN) and the tax period for which you are filing this schedule. b Check here if you had no shipments to report during this reporting period. Step 2: Tell us about the alcoholic liquors you shipped into Illinois You must provide invoice number (include the invoice date) and purchasers’ account number. Tell us the name and address of whom you sold or shipped the alcoholic liquors you are reporting. Report the total actual wine gallonage equivalent for each class of alcoholic liquor per invoice number. What if I need assistance? If you have questions about Schedule L, call our Springfield office weekdays from 8:00 a.m. to 4:30 p.m. at 217 785-2622 or write to us at the address listed above. Grand total: • If you are filing only one page, copy the “Page subtotal” amounts to the “Grand total” lines. RL-26-L (R-04/06) • If you are filing multiple pages, add all “Page subtotals” together for each liquor class and write each sum on the appropriate “Grand total” line on the last page. This form is authorized by the Liquor Control Act of 1934. Disclosure of this information is REQUIRED. Failure to provide information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-1493 American LegalNet, Inc. www.FormsWorkflow.com State of Illinois LIQUOR CONTROL COMMISSION 100 WEST RANDOLPH, SUITE 7-801, CHICAGO, IL 60601 PH: 312-814-2206 FAX: 312-814-2241 TDD (312) 814-1844 APPLICATION FOR REGISTRATION MANUFACTURER’S REGISTERED AGENT CURRENT LIQUOR LICENSE NO. TYPE OR PRINT INFORMATION APPLICANT’S NAME (Business, Partnership, Corporation) APPLICATION DATE DBA OR TRADE NAME BUSINESS PHONE BUSINESS STREET ADDRESS CITY STATE ZIP NAME, ADDRESS, PHONE OF MANUFACTURER’S AGENT(S) FOR WHICH IDENTIFICATION CARD IS REQUESTED. FOR EACH INDIVIDUAL LISTED, THE APPLICANT MUST ATTACH A STATEMENT OF REPRESENTATION. ATTACH ADDITIONAL SHEETS, IF NECESSARY. NAME PHONE ADDRESS, CITY, STATE, ZIP CODE NAME PHONE ADDRESS, CITY, STATE, ZIP CODE NAME PHONE ADDRESS, CITY, STATE, ZIP CODE DOES THE APPLICANT OR ASSOCIATE HOLD ANY RETAIL ALCOHOL BEVERAGE LICENSE, OR ANY FINANCIAL OR OTHER INTEREST NO IN SUCH A LICENSE OR ESTABLICHMENT? YES IF YES, DESCRIBE AND PROVIDE CURRENT LICENSE NUMBER. HAS THE APPLICANT, PARTNERS OR OFFICERS, EVER BEEN CONVICTED OF ANY VIOLATION OF THE ILLINOIS LIQUOR CONTROL ACT OR NO IF YES, GIVE FULL DETAILS. YES A FELONY IN THIS STATE, ANY OTHER STATE, OR UNDER FEDERAL LIQUOR LAWS? PRINT FULL NAME AND TITLE OF APPLICANT SIGNATURE OF APPLICANT DATE NOTE: IDENTIFICATION CARDS MUST BE OBTAINED FOR EACH SALES REPRESENTATIVE EMPLOYED. CARDS EXPIRE CONCURRENT WITH MANUFACTURER’S LIQUOR LICENSE. IL 567-0053 (10/2005) Printed on Recycled Paper American LegalNet, Inc. www.FormsWorkflow.com State of Illinois LIQUOR CONTROL COMMISSION 100 WEST RANDOLPH, SUITE 7-801, CHICAGO, IL 60601 PH: 312-814-2206 FAX: 312-814-2241 TDD (312) 814-1844 STATEMENT OF REPRESENTATION REGISTRATION OF MANUFACTURER’S AGENT as I (Name) (Title) have a contractual for (Name of Manufacturer) agreement with (Name of Manufacturer’s Agent) to represent and promote our products. This agreement covers the follwing territory(ies): I understand that under Illinois Law: Registration of agents, representatives, or persons acting on behalf of a manufacturer is fulfilled by submitting a form to the Commission. The form shall be developed by the Commission and shall include the name and address of the applicant, the name and address of the manufacturer he or she represents, the territory or areas assigned to sell to or discuss pricing terms of alcoholic liquor, and any other questions deemed appropriate and necessary. All statements in the forms required to be made by law or by rule shall be deemed material, and any person who knowingly misstates any material fact under oath in an application is guilty of a Class B misdemeanor. Fraud, misrepresentation, false statements, misleading statements, evasions, or suppression of material facts in the securing of a registration are grounds for suspension or revocation of the registration. 235 ILCS 5/5-1 Signature of Manufacturer’s Agent Signature of Manufacturer IL 567-0054 (10/2005) Social Security Number Title Date of Birth Date Date Printed on Recycled Paper American LegalNet, Inc. www.FormsWorkflow.com