Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application For State Of Illinois Non-Beverage Users License Alcoholic Liquor Form. This is a Illinois form and can be use in Liquor Control Commission Statewide.
Loading PDF...
Tags: Application For State Of Illinois Non-Beverage Users License Alcoholic Liquor, IL 567-0027, Illinois Statewide, Liquor Control Commission
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-BEVERAGE USER’S ALCOHOLIC LIQUOR LICENSE
DEFINITION
A non-beverage user’s license shall allow the licensee to purchase alcoholic liquor from a licensed manufacturer
or importing distributor, without the impostion of any tax upon the business of such licensed manufacturer or
importing distributor as to such alcoholic liquor to be used by such licensee solely for the non-beverage purposes
set forth in Section 8-1 of the Illinois Liquor Control Act, and such licenses shall be divided and classified and shall
permit the purchase, possession and use of limited and stated quantities of alcoholic liquor.
!
!
!
!
!
500 Gal. . . . . . . . . . . . . . . $24.00
CLASS 1 . . . . . . . . . . . . . . . . . . . Not to exceed . . . . . . . . . .
CLASS 2 . . . . . . . . . . . . . . . . . . . Not to exceed . . . . . . . . . . 1,000 Gal. . . . . . . . . . . . . . . $60.00
CLASS 3 . . . . . . . . . . . . . . . . . . . Not to exceed . . . . . . . . . . 5,000 Gal. . . . . . . . . . . . . . . $120.00
CLASS 4 . . . . . . . . . . . . . . . . . . . Not to exceed . . . . . . . . . . 10,000 Gal. . . . . . . . . . . . . . . $240.00
CLASS 5 . . . . . . . . . . . . . . . . . . . Not to exceed . . . . . . . . . . 50,000 Gal. . . . . . . . . . . . . . . $600.00
! NO FEE
Hospitals, Sanitariums or Clinics, Universities, Colleges of Learning or Schools, (when the use
of alcoholic liquor is strictly medicinal, mechanical, or scientific) and Laboratories (when the
use of alcoholic liquor is exclusively for the purpose of Scientific Research) are not required to
pay a fee for a non-beverage user’s license.
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 567-0027 (03/2006)
Printed on Recycled Paper
Page 1 of 4
American LegalNet, Inc.
www.FormsWorkflow.com
FOR OFFICE
USE ONLY
LICENSE NO.
DATE ISSUED
EXPIRATION DATE
Application for State of Illinois Non-Beverage User’s License Alcoholic Liquor
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.
TELEPHONE
Enter the area code/telephone number/extension of the corporation, partnership etc.
AREA CODE/TELEPHONE NO.
(
3.
)
EXT.
COUNTY
Enter the County in which the business is located.
COUNTY NAME
4.
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
5.
DBA NAME
ADDRESS (Location of place of business for which application is made)
Enter the street address, city, state, and Zip Code of the corporation, partnership, etc..
ADDRESS
6.
IL SECRETARY OF STATE
CORPORATION FILE NUMBER (If applicable)
FILE NUMBER
IL 567-0027 (03/2006)
CITY
STATE
ZIP CODE
7. DATE OF INCORPORATION/REGISTRATION
(If applicable)
DATE OF INCORPORATION/REGISTRATION
Printed on Recycled Paper
Page 2 of 4
American LegalNet, Inc.
www.FormsWorkflow.com
A. CORPORATE/BUSINESS(DBA) INFORMATION (CON’T)
1.
PREVIOUS NON-BEVERAGE USER LICENSE NUMBER (If applicable)
NON-BEVERAGE LICENSE NO.
2.
STATE NATURE OF BUSINESS
Enter the Corporate Entity type of business
NATURE OF BUSINESS
3.
PURPOSE FOR WHICH ALCOHOLIC LIQUORS ARE TO BE USED
4.
PERSON COMPLETING APPLICATION
Enter the Name, Title/Position, and Telephone number of the person completing this application.
NAME
B.
TELEPHONE NO.
TITLE/POSITION
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 of ownership.
HOME ADDRESS
NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX
CITY
TITLE/POSITION
AREA CODE/TELEPHONE NO.
(
DATE OF BIRTH
SEX
CITY
TITLE/POSITION
NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NO.
DATE OF BIRTH
TITLE/POSITION
AREA CODE/TELEPHONE NO.
Printed on Recycled Paper
ZIP
% OWNED
)
CITY
(
IL 567-0027 (03/2006)
STATE
HOME ADDRESS
SEX
% OWNED
AREA CODE/TELEPHONE NO.
(
ZIP
)
HOME ADDRESS
NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NO.
STATE
STATE
ZIP
% OWNED
)
Page 3 of 4
American LegalNet, Inc.
www.FormsWorkflow.com
B.
OWNERSHIP INFORMATION (CON’T)
ADDITIONAL MEMBERS/OFFICERS (if needed)
NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NO.
DATE OF BIRTH
HOME ADDRESS
SEX
CITY
TITLE/POSITION
AREA CODE/TELEPHONE NO.
(
NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX
NAME (LAST, FIRST, MIDDLE INITIAL)
DATE OF BIRTH
CITY
% OWNED
TITLE/POSITION
AREA CODE/TELEPHONE NO.
STATE
CITY
TITLE/POSITION
AREA CODE/TELEPHONE NO.
(
ZIP
% OWNED
)
HOME ADDRESS
SEX
ZIP
)
HOME ADDRESS
(
SOCIAL SECURITY NO.
STATE
STATE
ZIP
% OWNED
)
AFFIDAVIT
The above information supplied for the purpose of inducing the Illinois Liquor Control Commission to issue a
Non-Beverage User’s license to the applicant herein 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(s).
IL 567-0027 (03/2006)
Printed on Recycled Paper
Page 4 of 4
American LegalNet, Inc.
www.FormsWorkflow.com
