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 BROKER’S LIQUOR LICENSE DEFINITIONS: “Broker” means (i) a person who solicits orders for or offers to sell or supply alcoholic liquors to retailers for a fee or commission, for or on behalf of a person authorized to manufacture or sell at wholesale alcoholic liquors within or without the State or (ii) a person within this State, other than a retail licensee, who, for a fee or commission, promotes, solicits, or accepts orders for alcoholic liquor, for use or consumption and not for resale, to be shipped from this State and delivered to residents outside of this State by an express company, common carrier, or contract carrier. This section does not apply to any person who promotes, solicits, or accepts orders for wine as specifically authorized in Section 6-29 of this Act. FEE BROKER’S LIQUOR LICENSE $600.00 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 CONTROLACT (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 567-0060 (03/2006) Printed on Recycled Paper PAGE 1 OF 6 American LegalNet, Inc. www.FormsWorkflow.com General Information - Broker a. Brokers CANNOT for a fee or commission promote, solicit, or accept orders for alcoholic liquor at retail, for use and consumption and not for resale, to Illinois residents. b. Brokers CAN for a fee or consumption promote, solicit, or accept, orders for alcoholic liquor at retail, for use and consumption and not for resale, to residents of other states outside of Illinois, pursuant to the laws of those states. c. Brokers, located within or outside of Illinois, CAN for a fee or commission promote, so licit, or accept orders for alcoholic liquor, from licensed Illinois retailers. NOTE: All alcoholic liquors sold to licensed Illinois retailers must be shipped by licensed Illinois distributors, importing distributors, or foreign importers. d. Brokers, located within or outside of Illinois, CAN on behalf of a licensed Illinois retailer make contact with distillers, rectifiers, brewers or manufacturers or any other party within or outside of Illinois in order that alcoholic liquors be shipped to a licensed Illinois distributor, importing distributor or foreign importer, whether such solicitation or offer is consummated within or outside of Illinois. Who Does Not Need to be Licensed as a Broker? Persons who promote, solicit or accept orders for wine products on behalf of a lawfully licensed entity as part of a reciprocal wine shipment to residents over the age of 21 for personal use and not for resale as long as it is not more than 18 liters of wine. What Will Happen to Persons Making Prohibited Sales of Alcoholic Liquor? Any person discovered making unlawful sales of alcoholic liquors is in violation of the Illinois Liquor Control Act of 1934 and shall receive a “Cease and Desist Order” from the Illinois Liquor Control Commission. Furthermore, such person will also be subject to appropriate action by the Illinois Department of Revenue and the States’Attorney in the county in which the alcoholic liquor product was delivered. IL 567-0060 (03/2006) PAGE 2 OF 6 American LegalNet, Inc. www.FormsWorkflow.com FOR OFFICE USE ONLY LICENSE NO. DATE ISSUED EXPIRATION DATE COUNTER † Application for State of Illinois Broker’s Liquor License 1. APPLICANT - CORPORATE INFORMATION A. 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 # B. ILLINOIS BUSINESS TAX NUMBER (IBT OR SALES TAX NO.) IF APPLICABLE Enter the eight-digit Illinois Department of Revenue Business Tax (Sales Tax) Number. 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 (312) 814-5258 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. CORPORATE NAME (Also list DBA name if different from corporate 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 567-0060 (03/2006) CITY STATE ZIP CODE PAGE 3 OF 6 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: If C, D or E is checked, indicate your current Secretary of State file number here 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. 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 567-0060 (03/2006) STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED % PAGE 4 OF 6 American LegalNet, Inc. www.FormsWorkflow.com 4. MISCELLANEOUS INFORMATION A. INTERNET ADDRESS (if applicable) Please provide Internet address. For example, www:state.il.us/lcc INTERNET ADDRESS C. FEDERAL REGISTRATION AND RETURN To sell alcoholic beverages, you are required to register with the Federal Alcohol and Tobacco Tax and Trade Bureau (TTB) on a yearly basis. HAVE YOU FILED TTB FORM 5630.5 “ANNUAL SPECIAL TAX REGISTRATION AND RETURN”? YES NO If NO is checked, TTB Form 5630.5 may be obtained from the National Revenue Center at 800-937-8864 or downloaded at www.ttb.gov (www.ttb.gov/forms/pdfs5600/f56305.pdf). 5. LICENSE HISTORY A. FIRST LICENSE APPLICATION - LICENSE HISTORY Indicate by checking the correct box whether or not this is the applicant’s first application for a State liquor license at any premises. If you check “no”, indicate the date of your first State liquor license application. Also indicate whether the license was granted, denied or withdrawn. Provide the address of your first State liquor license application and the type of license applied. If you have ever had a license application denied or if you ever withdrew an application, please provide a written statement describing the reason and circumstances. IS THIS YOUR FIRST STATE LICENSE APPLICATION? YES NO IF NO, PROVIDE DATE FIRSTAPPLIED: DISPOSITION: GRANTED DENIED WITHDRAWN ADDRESS OF FIRST STATE APPLICATION: IL 567-0060 (03/2006) PAGE 5 OF 6 American LegalNet, Inc. www.FormsWorkflow.com 6. ELIGIBILITY QUESTIONS These questions apply to the applicant and any other person listed under Section 3. 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. 6-17 YES NO HAVE YOU FAILED OR NEGLECTED TO REGISTER WITH THE FEDERAL TAX & TRADE BUREAU (TTB)? IF SO, PLEASE CONTACT THE TTB AT 800-937-8864 OR 513-684-2979. 6-18 YES NO ARE YOU DELINQUENT IN THE PAYMENT OF ANY ILLINOIS BUSINESS TAXES (SALES, WITHHOLDING, ETC.)? 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”? 6-28 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? 7. 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 567-0060 (03/2006) TITLE/POSITION DATE PAGE 6 OF 6 American LegalNet, Inc. www.FormsWorkflow.com