Illinois Liquor Control Commission 100 W. RANDOLPH ST, SUITE 7-801 CHICAGO, ILLINOIS 60601 PH: 312-814-2206 FAX: 312-814-2241 TDD: 312-814-1844 Pat Quinn Governor 101 W. JEFFERSON ST, SUITE 3-525 SPRINGFIELD, ILLINOIS 62702 PH: 217-782-2136 FAX: 217-524-1911 WEB SITE: www.state.il.us/LCC APPLICATION FOR STATE OF ILLINOIS MANUFACTURER’S LIQUOR LICENSE DEFINITIONS: A manufacturer is every brewer, fermenter, distiller, rectifier, wine maker, blender, processor, bottler or person who fills or refills an original package, whether for himself or for another, and others engaged in brewing, fermenting, distilling, rectifying or bottling alcoholic liquors as above defined. To manufacture means to distill, rectify, ferment, brew, make, mix, concoct, process, blend, bottle or fill an original package with an alcoholic liquor, whether for oneself or for another, and includes blending but does not include the mixing or other preparation of drinks for serving by those persons authorized and permitted in this Act to serve drinks for consumption on the premises where sold. All containers or packages of blended alcoholic liquors shall have affixed thereto a label setting forth and stating clearly the names of all ingredients which the blended alcoholic liquors offered for sale shall contain. CLASS 1: DISTILLER $3,600.00 FEE: A Distiller is a person who distills, ferments, brews, makes, mixes, concocts, processes, blends, bottles or fills an original package with any alcoholic liquor. A distiller may make sales and deliveries of alcoholic liquor to distillers, rectifiers, importing distributors, distributors, and non-beverage users and to no other licensees. This includes a manufacturer of wine, but does not include a manufacturer of beer or bottler of wine. SUPPORTING DOCUMENTS REQUIRED: • ENCLOSED REGISTRATION STATEMENT; • COPY OF FEDERAL LABEL APPROVAL(S). VISIT WWW.TTB.GOV TO DOWNLOAD THE F 5100.31 APPLICATION FORM; • TAX BOND ACQUIRED BY ONE OF THE FOLLOWING ENCLOSED FORMS: a) RL-1 TAX STATEMENT OF LIABILITY; b) REG-4-A (LIQUOR GALLONAGE TAX BOND) CERTIFICATE OF DEPOSIT; or c) REG-4-D LETTER OF CREDIT BOND. CLASS 2: RECTIFIER IF APPLICABLE, ENCLOSED STATEMENT OF REPRESENTATION— REGISTRATION OF MANUFACTURER’S AGENT (IL 567-0054). IF APPLICABLE, ENCLOSED APPLICATION FOR REGISTRATION— MANUFACTURER’S REGISTERED AGENT (IL 567-0053). SEE SECTION 8 FOR DEFINITION $3,600.00 FEE: A Rectifier is any person who rectifies, ferments, brews, makes, mixes, concocts, processes, blends, bottles or fills an original package with any alcoholic liquor, other than by original or continuous distillation. SUPPORTING DOCUMENTS REQUIRED: • ENCLOSED REGISTRATION STATEMENT; • COPY OF FEDERAL LABEL APPROVAL(S). VISIT WWW.TTB.GOV TO DOWNLOAD THE F 5100.31 APPLICATION FORM; • TAX BOND ACQUIRED BY ONE OF THE FOLLOWING ENCLOSED FORMS: a) RL-1 TAX STATEMENT OF LIABILITY; b) REG-4-A (LIQUOR GALLONAGE TAX BOND) CERTIFICATE OF DEPOSIT; or c) REG-4-D LETTER OF CREDIT BOND. CLASS 3: BREWER IF APPLICABLE, ENCLOSED STATEMENT OF REPRESENTATION— REGISTRATION OF MANUFACTURER’S AGENT (IL 567-0054). IF APPLICABLE, ENCLOSED APPLICATION FOR REGISTRATION— MANUFACTURER’S REGISTERED AGENT (IL 567-0053). SEE SECTION 8 FOR DEFINITION $900.00 FEE: A Brewer is any person who is engaged in the manufacture of beer. A brewer may make sales and deliveries of beer to importing distributors and distributors, in accordance with the provisions of the Illinois Liquor Control Act. SUPPORTING DOCUMENTS REQUIRED: • ENCLOSED REGISTRATION STATEMENT; • COPY OF FEDERAL LABEL APPROVAL(S). VISIT WWW.TTB.GOV TO DOWNLOAD THE F 5100.31 APPLICATION FORM; • TAX BOND ACQUIRED BY ONE OF THE FOLLOWING ENCLOSED FORMS: a) RL-1 TAX STATEMENT OF LIABILITY; b) REG-4-A (LIQUOR GALLONAGE TAX BOND) CERTIFICATE OF DEPOSIT; or c) REG-4-D LETTER OF CREDIT BOND. CLASS 4: FIRST-CLASS WINE MANUFACTURER IF APPLICABLE, ENCLOSED STATEMENT OF REPRESENTATION— REGISTRATION OF MANUFACTURER’S AGENT (IL 567-0054). IF APPLICABLE, ENCLOSED APPLICATION FOR REGISTRATION— MANUFACTURER’S REGISTERED AGENT (IL 567-0053). SEE SECTION 8 FOR DEFINITION $600.00 FEE: A wine-manufacturer means a person who is engaged in the manufacture of wine. A first-class wine-manufacturer may make sales and deliveries of up to 50,000 gallons of wine to manufacturers, importing distributors and distributors, and to no other licensees. REQUIRED DOCUMENTS: • ENCLOSED REGISTRATION STATEMENT; • COPY OF FEDERAL LABEL APPROVAL(S). VISIT WWW.TTB.GOV TO DOWNLOAD THE F 5100.31 APPLICATION FORM; • TAX BOND ACQUIRED BY ONE OF THE FOLLOWING ENCLOSED FORMS: a) RL-1 TAX STATEMENT OF LIABILITY; b) REG-4-A (LIQUOR GALLONAGE TAX BOND) CERTIFICATE OF DEPOSIT; or c) REG-4-D LETTER OF CREDIT BOND. IL 567-0015-A (08/2010) IF APPLICABLE, ENCLOSED STATEMENT OF REPRESENTATION— REGISTRATION OF MANUFACTURER’S AGENT (IL 567-0054). IF APPLICABLE, ENCLOSED APPLICATION FOR REGISTRATION— MANUFACTURER’S REGISTERED AGENT (IL 567-0053). SEE SECTION 8 FOR DEFINITION Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com CLASS 5: SECOND-CLASS WINE MANUFACTURER $1,200.00 FEE: A wine-manufacturer means a person who is engaged in the manufacture of wine. A second-class wine-manufacturer may make sales and deliveries of more than 50,000 gallons of wine to manufacturers, importing distributors and distributors and to no other licensees. SUPPORTING DOCUMENTS REQUIRED: • ENCLOSED REGISTRATION STATEMENT; • COPY OF FEDERAL LABEL APPROVAL(S). VISIT WWW.TTB.GOV TO DOWNLOAD THE F 5100.31 APPLICATION FORM; • TAX BOND ACQUIRED BY ONE OF THE FOLLOWING ENCLOSED FORMS: a) RL-1 TAX STATEMENT OF LIABILITY; b) REG-4-A (LIQUOR GALLONAGE TAX BOND) CERTIFICATE OF DEPOSIT; or c) REG-4-D LETTER OF CREDIT BOND. CLASS 6: FIRST-CLASS WINE MAKER IF APPLICABLE, ENCLOSED STATEMENT OF REPRESENTATION— REGISTRATION OF MANUFACTURER’S AGENT (IL 567-0054). IF APPLICABLE, ENCLOSED APPLICATION FOR REGISTRATION— MANUFACTURER’S REGISTERED AGENT (IL 567-0053). SEE SECTION 8 FOR DEFINITION $600.00 FEE: A first-class wine-maker’s license shall allow the manufacturer of up to 50,000 gallons of wine per year, and the storage and sale of such wine to distributors and retailers in the state and to persons without the State, as may be permitted by law. SUPPORTING DOCUMENTS REQUIRED: • ENCLOSED REGISTRATION STATEMENT; • COPY OF FEDERAL LABEL APPROVAL(S). VISIT WWW.TTB.GOV TO DOWNLOAD THE F 5100.31 APPLICATION FORM; • TAX BOND ACQUIRED BY ONE OF THE FOLLOWING ENCLOSED FORMS: a) RL-1 TAX STATEMENT OF LIABILITY; b) REG-4-A (LIQUOR GALLONAGE TAX BOND) CERTIFICATE OF DEPOSIT; or c) REG-4-D LETTER OF CREDIT BOND. CLASS 7: SECOND CLASS WINE MAKER IF APPLICABLE, ENCLOSED STATEMENT OF REPRESENTATION— REGISTRATION OF MANUFACTURER’S AGENT (IL 567-0054). IF APPLICABLE, ENCLOSED APPLICATION FOR REGISTRATION— MANUFACTURER’S REGISTERED AGENT (IL 567-0053). SEE SECTION 8 FOR DEFINITION $1,200.00 FEE: A wine-maker is a person engaged in the making of between 50,000 and 100,000 gallons of wine annually. A second-class wine-maker’s license shall allow the manufacture of between 50,000 and 100,000 gallons of wine per year, and the storage and sale of such wine to distributors in this State and to persons without the State, as may be permitted by law. A second class wine-maker’s license shall allow the sale of no more than 10,000 gallons of the licensee’s wine directly to retailers. SUPPORTING DOCUMENTS REQUIRED: • ENCLOSED REGISTRATION STATEMENT; • COPY OF FEDERAL LABEL APPROVAL(S). VISIT WWW.TTB.GOV TO DOWNLOAD THE F 5100.31 APPLICATION FORM; • TAX BOND ACQUIRED BY ONE OF THE FOLLOWING ENCLOSED FORMS: a) RL-1 TAX STATEMENT OF LIABILITY; b) REG-4-A (LIQUOR GALLONAGE TAX BOND) CERTIFICATE OF DEPOSIT; or c) REG-4-D LETTER OF CREDIT BOND. CLASS 8: LIMITED WINE MANUFACTURER IF APPLICABLE, ENCLOSED STATEMENT OF REPRESENTATION— REGISTRATION OF MANUFACTURER’S AGENT (IL 567-0054). IF APPLICABLE, ENCLOSED APPLICATION FOR REGISTRATION— MANUFACTURER’S REGISTERED AGENT (IL 567-0053). SEE SECTION 8 FOR DEFINITION $120.00 FEE: A limited wine-manufacturer may make sales and deliveries not to exceed 40,000 gallons of wine per year to distributors and to nonlicensees in accordance with the provisions of the Illinois Liquor Control Act. A limited wine manufacturer uses only grapes, berries, other fruits, fruit products, honey and vegetables produced or grown in Illinois, except as defined in the Illinois Liquor Control Act, Section 5/1-3.31. SUPPORTING DOCUMENTS REQUIRED: • ENCLOSED REGISTRATION STATEMENT; • COPY OF FEDERAL LABEL APPROVAL(S). VISIT WWW.TTB.GOV TO DOWNLOAD THE F 5100.31 APPLICATION FORM; • TAX BOND ACQUIRED BY ONE OF THE FOLLOWING ENCLOSED FORMS: a) RL-1 TAX STATEMENT OF LIABILITY; b) REG-4-A (LIQUOR GALLONAGE TAX BOND) CERTIFICATE OF DEPOSIT; or c) REG-4-D LETTER OF CREDIT BOND. CLASS 9: CRAFT DISTILLER IF APPLICABLE, ENCLOSED STATEMENT OF REPRESENTATION— REGISTRATION OF MANUFACTURER’S AGENT (IL 567-0054). IF APPLICABLE, ENCLOSED APPLICATION FOR REGISTRATION— MANUFACTURER’S REGISTERED AGENT (IL 567-0053). SEE SECTION 8 FOR DEFINITION $1,800.00 FEE: A craft distiller license shall allow the manufacture of up to 5,000 gallons of spirits by distillation per year and the storage of such spirits. If a craft distiller licensee is not affiliated with any other manufacturer, then the craft distiller licensee may sell such spirits to distributors in this State and non-licensees to the extent permitted by any exemption approved by the Commission persuant to Section 6-4 of the Liquor Control Act. Any craft distiller licensed under this Act how who on the effective date (July 28, 2010) of this amendatory Act of the 96th General Assembly was licensed as a distiller and manufactured no more spirits than permitted by this Section shall not be required to pay the initial licensing fee. SUPPORTING DOCUMENTS REQUIRED: • ENCLOSED REGISTRATION STATEMENT; • COPY OF FEDERAL LABEL APPROVAL(S). VISIT WWW.TTB.GOV TO DOWNLOAD THE F 5100.31 APPLICATION FORM; • TAX BOND ACQUIRED BY ONE OF THE FOLLOWING ENCLOSED FORMS: a) RL-1 TAX STATEMENT OF LIABILITY; b) REG-4-A (LIQUOR GALLONAGE TAX BOND) CERTIFICATE OF DEPOSIT; or c) REG-4-D LETTER OF CREDIT BOND. IL 567-0015-A (08/2010) IF APPLICABLE, ENCLOSED STATEMENT OF REPRESENTATION— REGISTRATION OF MANUFACTURER’S AGENT (IL 567-0054). IF APPLICABLE, ENCLOSED APPLICATION FOR REGISTRATION— MANUFACTURER’S REGISTERED AGENT (IL 567-0053). SEE SECTION 8 FOR DEFINITION Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com FOR OFFICE USE ONLY LICENSE NO. EXPIRATION DATE DATE ISSUED COUNTER 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. Application for State of Illinois Manufacturer’s Liquor License 1. APPLICANT - CORPORATE INFORMATION If you want your renewal application, your license certificate and other ILCC correspondence sent to your “corporate” address, please check this box. 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.) Enter the eight-digit Illinois Dept. 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, please call 312-814-5232 (Chicago), 217-785-2889 (Springfield), 800-732-8866 (toll-free) or visit www.tax.illinois.gov and click on the “For Businesses...” link (located under “Illinois e-Services”), and then the “Business Registration” link. 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 name printed on your Illinois Department of Revenue Sales Tax Certificate. CORPORATE NAME F. DBA NAME ADDRESS Enter the street address, city, state, and Zip Code of the sole proprietorship, corporation, etc.. ADDRESS IL 567-0015-A (08/2010) 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. ASSUMED NAME DATE FILED WITH COUNTY CLERK: PARTNERSHIP DATE OF FORMATION: ILLINOIS CORPORATION DATE OF INCORPORATION: FOREIGN CORPORATION LIMITED LIABILITY COMPANY 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 by every individual applicant, sole proprietor, partner, corporate officer or director (whether or not they own any stock), shareholder owning in the aggregate equal to or more than 5% of the stock, (including officers, directors and stockholders of 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 have 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. NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. B. 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 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 HOME ADDRESS CITY TITLE/POSITION AREA CODE/TELEPHONE NO. TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% INTEREST IL 567-0015-A (08/2010) 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. WAREHOUSING If any of your inventory is warehoused, provide the name, street address, city, state, Zip Code and county of the warehouse. ADDRESS STATE CITY ZIP CODE COUNTY B. LEASED PREMISES If you lease your premises, the lease must cover the full term of the license. If you lease, provide the landlord’s name, telephone number, street address, city, state, Zip Code and county. AREA CODE/TELEPHONE NO. LANDLORD NAME ADDRESS STATE CITY ZIP CODE COUNTY 5. LICENSE HISTORY A. FIRST LICENSE APPLICATION - LICENSE HISTORY Indicate by checking the correct box whether or not this is the corporation’s, sole proprietorship’s, etc’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. 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 FIRST APPLIED: DISPOSITION: GRANTED DENIED WITHDRAWN ADDRESS OF FIRST STATE APPLICATION: IL 567-0015-A (08/2010) 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 Question 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. 6-18 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 5/281.1(a)-(d) “SYNDICATED GAMBLING;” AND 720 ILCS 5/28-3 “KEEPING A GAMBLING PLACE”? 6-26 YES NO DO YOU POSSESS A CURRENT FEDERAL WAGERING STAMP? (ISSUED BY THE UNITED STATES INTERNAL REVENUE SERVICE TO TAX WAGERING ACTIVITY) 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? 6-30 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? 7. HOURS OF OPERATION List the daily hours open for business. This information will assist Commission field agents in choosing an inspection time which causes the least disruption to the business. MON TUES WED THURS FRI SAT SUN 8. MANUFACTURER’S REGISTERED AGENT REQUIREMENTS 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”. 9. 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. (NOTE: IF THE PERSON SIGNING THIS APPLICATION IS NOT LISTED IN SECTION 3, THEY MUST PROVIDE THE STATE WITH THEIR PERSONAL INFORMATION AS INDICATED IN SECTION 3 EVEN IF THEY DO NOT OWN 5% OR MORE OF THE BUSINESS.) SIGNATURE OF APPLICANT/AUTHORIZED AGENT IL 567-0015-A (08/2010) TITLE/POSITION DATE Page 6 of 6 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 GEOGRAPHICAL TERRITORY TIME PERIOD 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-1 Liquor Tax Statement of Liability Read this information first You must complete this form and submit it to us with your completed bond forms. Step 1: Identify your business Name ____________________________________________ DBA IBT no. ____ ____ ____ ____ ____ ____ ____ ____ ____________________________________________ Address __________________________________________ Number and street __________________________________________________ City State ZIP Step 2: Estimate your average monthly tax liability and bond amount 1 What is your estimated average monthly liquor tax liability? 2 Multiply Line 1 by 2. This is your bond amount. $______________________ $______________________ Note: The minimum bond amount is $1,000 and the maximum amount is $100,000. Step 3: Sign below Mail this form to Under penalty of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete. __________________________________________________ Signature Date ILLINOIS DEPARTMENT OF REVENUE PO BOX 19039 SPRINGFIELD IL 62794-9039 If you have any questions, call us at 217 782-6997. RL-1 (N-8/95) IL-492-3536 SOY-BASE INK RECYCLED PAPER Illinois Department of Revenue RL-1 Liquor Tax Statement of Liability Read this information first You must complete this form and submit it to us with your completed bond forms. Step 1: Identify your business Name ____________________________________________ DBA IBT no. ____ ____ ____ ____ ____ ____ ____ ____ ____________________________________________ Address __________________________________________ Number and street __________________________________________________ City State ZIP Step 2: Estimate your average monthly tax liability and bond amount 1 What is your estimated average monthly liquor tax liability? 2 Multiply Line 1 by 2. This is your bond amount. $______________________ $______________________ Note: The minimum bond amount is $1,000 and the maximum amount is $100,000. Step 3: Sign below Mail this form to Under penalty of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete. __________________________________________________ Signature Date ILLINOIS DEPARTMENT OF REVENUE PO BOX 19039 SPRINGFIELD IL 62794-9039 If you have any questions, call us at 217 782-6997. RL-1 (N-8/95) IL-492-3536 American LegalNet, Inc. www.FormsWorkFlow.com SOY-BASE INK RECYCLED PAPER Illinois Dept. of Revenue Directions for completing: • REG-4-A (Financial Responsibility Bond); and • REG-4-D (Financial Institution Irrevocable Letter of Credit Bond) You must provide this information to the bank or insurance company that will be providing your bond. A separate bond is required for each location. You will not be issued a certificate of registration and cannot be legally registered to do business in Illinois until we receive your bond. Your bond can be in the form of: Insurance bonds: Form REG-4-A, Financial Responsibility Bond, must be completed entirely by your insurance company. Your business’ name and address must be identical to the information you have registered with us. The insurance company issuing your bond must: • Sign; • Stamp their insurance seal; • Assign a bond number; and • If applicable, attach their power of attorney stating the attorney-in-fact’s name. All of your business’ owners, officers, or partners must sign the bond. If you are a corporation, the president and secretary must sign the bond. You must also affix your corporate seal. Note: The original bond and power of attorney must be sent to us. Letter of Credit: Form REG-4-D, Financial institution Irrevocable Letter of Credit Bond, must be completed entirely by your bank if you are providing a bank letter of credit. Your business’ name and address must be identical to the information you have registered with us. The bank issuing your letter of credit must: • Stamp their bank seal; and • Send to us the original bank letter of credit containing the seal. Note: The Letter of Credit must be signed by an authorized officer of the banking institution. Certificates of Deposit: Any bank may issue you a Certificate of Deposit to satisfy your bond requirements. A Certificate of Deposit must: • Be made payable to the Director, Illinois Department of Revenue; • State that the Certificate of Deposit is automatically renewable; • Have a maturity date of 12 months or less; • Have your business’ name and identification number (i.e. FEIN or Social Security number). If you prefer, you can send us a cashier’s check and we will purchase the Certificate of Deposit for you. Note: The original Certificate of Deposit must be sent to us, receipts are not acceptable. American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com 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 Printed on Recycled Paper Date of Birth Date Date 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