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 IN SUCH A LICENSE OR ESTABLISHMENT? IF YES, DESCRIBE AND PROVIDE CURRENT LICENSE NUMBER. ! NO ! YES HAS THE APPLICANT, PARTNERS OR OFFICERS, EVER BEEN CONVICTED OF ANY VIOLATION OF THE ILLINOIS LIQUOR CONTROL ACT OR A FELONY IN THIS STATE, ANY OTHER STATE, OR UNDER FEDERAL LIQUOR LAWS? ! NO ! YES IF YES, GIVE FULL DETAILS. 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