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 SPECIAL EVENT RETAILER’S LIQUOR LICENSE (NOT-FOR-PROFIT) DEFINITION: A Special Event Retailer’s License (Not-for-Profit) shall permit the licensee to purchase alcoholic liquors from an Illinois licensed distributor (unless the licensee purchases less than $500 of alcoholic liquors for the special event, in which case the licensee may purchase the alcoholic liquors from a licensed retailer), and shall allow the licensee to sell and offer for sale, at retail, alcoholic liquors for use or consumption, but not for resale in any form, and only at the location and on the specific date(s) designated for the special event on the license. An “event” can be defined as a single theme. A Special Event Retailer’s License must be obtained for each single theme per location with a maximum duration of 15 days. All not-forprofit corporations are required to secure a license for each 15-day increment and each special “event”. ELIGIBILITY: The Special Event Retailer’s License (Not-for-Profit) application form is to be used only for events conducted by an educational, fraternal, political, civic, religious or not-for-profit organization. DO NOT use this form if you have a current Illinois Retailer’s liquor license (see Special Use Permit license instructions). Local liquor licensing authority approval is required for this license. Dram shop insurance to the maximum limit is required for this license. FEE: $25.00 PER APPLICATION, IF THE EVENT IS: 1) A SINGLE THEME; 2) AT THE SAME LOCATION FOR NOT MORE THAN 15 DAYS FROM START TO FINISH; AND 3) APPLICATION IS RECEIVED AT LEAST 14 DAYS IN ADVANCE. ADD AN ADDITIONAL $25.00 TO EACH APPLICATION FEE IF YOU EXPECT THAT THE APPLICATION WILL NOT BE RECEIVED AT COMMISSION OFFICES AT LEAST 14 DAYS PRIOR TO THE SCHEDULED EVENT (LEAD TIME REQUIRED IN ORDER TO SCHEDULE SITE INSPECTIONS). NOTE: “FOR-PROFIT” ORGANIZATIONS WHICH CURRENTLY DO NOT HOLD A STATE LIQUOR LICENSE and wish to hold a special event will be required to obtain a standard Retailer’s Liquor License for $500.00 that covers the date(s) of the special event. This is the only way you will be able to purchase alcoholic beverages from a distributor. You will need to fill out the standard Retailer’s Liquor License application form (IL 567-0015). PRIVATE PARTY is an event where attendance is by invitation only, the host controls access to the premises, and alcoholic beverages are provided to invited guests at no charge. A Special Event Liquor License is not required for a private party. ON THE FOLLOWING PAGES, PLEASE PRINT OR TYPE THE INFORMATION REQUESTED IN THE SPACES PROVIDED. THE FORM MUST BEAR AN ORIGINAL SIGNATURE, THEREFORE NO FAXED SIGNATURES OR FORMS WITH PHOTOCOPIED/RUBBER STAMPED SIGNATURES WILL BE ACCEPTED. 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 567-0028 (07/2005) Printed on Recycled Paper Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com FOR OFFICIAL USE ONLY FOR OFFICE USE ONLY LICENSE NO. DATE ISSUED COUNTER † EXPIRATION DATE Application for State of Illinois Special Event Retailer’s Liquor License 1. APPLICANT INFORMATION Provide the corporate/organization name; provide the corporate/organization Federal Employer Identification Number (FEIN); provide your corporate/organization mailing address; county; and telephone number. FEDERAL EMPLOYER ID NO. NAME ADDRESS CITY STATE ZIP CODE COUNTY AREA CODE/TELEPHONE NO. 2. CERTIFICATION Public Act 90-596 was enacted to ensure that special event holders pay all required sales taxes if they hold more than two special events during a calendar year or if they are not a valid “not-for-profit” organization. Applicants for Special Event Retailer Not-for-profit Liquor licenses must now certify that both of the following conditions apply to this particular special event. Please check the boxes that apply. If either box is left unchecked, the Commission will issue this license as “NON-CERTIFIED” which may require the organization to pay sales taxes on the gross receipts from all sales of food and beverages at the event. The certifying officer must be listed under Section 5 of the application, having provided all required identifying information. Should you have any questions regarding sales tax liability or sales tax registration information, please call the Department of Revenue Toll Free Hotline at 800-732-8866. † I hereby certify that the organization which is applying for this Special Event Retailer Not-for-profit Liquor license is a valid “not-for-profit” entity which holds either a resale number [a resale sales tax number] issued under Section 2(c) of the Retailers’ Occupation Tax Act; a sales tax registration [a sales tax number] under Section 2(a) of the Retailers’ Occupation Tax Act; or a current, valid exemption identification number [a tax-exempt “E” number] issued under Section 1(g) of the Retailers’ Occupation Tax Act. hereby certify that the organization which is applying for Retailer Not-for-profit † ILiquor license has held no more than two such special events this Special Eventcalendar year (January during the current 1 - December 31). This special event must be included in your calculation. Signature of Applicant Title of Applicant Date 3. STATUS OF ORGANIZATION Check appropriate box and provide sales tax exemption details. † † † † † † A. B. C. D. E. F. EDUCATIONAL FRATERNAL POLITICAL CIVIC RELIGIOUS OTHER NOT-FOR-PROFIT IL 567-0028 (07/2005) DATE OF INCORPORATION: OR ATTACH AN ILLINOIS DEPARTMENT OF REVENUE SALES TAX EXEMPTION LETTER (SPECIFY) Printed on Recycled Paper Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com 4. SPECIAL EVENT DETAIL • Provide the date(s) and time(s) that the event will be held. When you receive your printed license certificate from the Commission, times will be listed in military time; i.e. “0200” = 2AM, “1200” = noon”; “2400” = midnight; etc. • Provide the address/location of the event. If an address is not available, provide specific instructions to enable our investigators to find the event. Please note: Only one location is allowed per application. • • Provide the name/type of the event; i.e. neighborhood festival, Octoberfest, fish fry, spaghetti dinner, etc. • Determine the total number of days covered by the event. If your neighborhood festival runs for 16 days, you will be required to fill out two applications and pay two fees. For example, if you are holding a fish fry on three successive Fridays (15 days) at the same location, you are only required to fill out a single application and pay a single application fee since the theme is identical, the total duration is 15 days or less, and the location is the same. Determine the total number of event themes/event types for which approval is requested. Use a separate application for each event theme/event type. DATE OF EVENT: EVENT STARTS (MONTH/DAY/YR) 5. EVENT TIME: TIME FROM ( AM/PM ) DATE OF EVENT: EVENT ENDS (MONTH/DAY/YR) EVENT TIME: TIME TO ( AM/PM ) LOCATION OF EVENT: STREET ADDRESS CITY/STATE/ZIP EVENT THEME: TYPE OF EVENT CORPORATE/ORGANIZATION OFFICER INFORMATION The individual signing this application at the bottom of page 4 MUST be listed in this section. NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. DATE OF BIRTH HOME ADDRESS SOCIAL SECURITY NO. DATE OF BIRTH SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. IL 567-0028 (07/2005) DATE OF BIRTH SEX AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. HOME ADDRESS NAME (LAST, FIRST, MIDDLE INITIAL) TITLE/POSITION HOME ADDRESS SEX CITY CITY TITLE/POSITION AREA CODE/TELEPHONE NO. Printed on Recycled Paper STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com 6. PRIOR LIQUOR LICENSE INFORMATION A. Is this your first state liquor license application? B. If this is not your first state liquor license application, provide the date of your first filing: C. Has the organization ever applied for and been denied a liquor license? Yes No complete written explanation of the circumstances on a separate sheet of paper. D. Has the organization had any previous Special Event Retailer’s Liquor License suspended or revoked? Yes No If yes, provide a complete written explanation of the circumstances on a separate sheet of paper. Yes No If so, provide a 7. LOCAL AUTHORITY APPROVAL You MUST submit proof of local authority approval for your special event. Generally, your local municipality will issue approval in the form of a letter, a certificate, or a rubber stamp. If the event is taking place in an unincorporated area, the County will need to provide the approval. If the event is taking place on State or Federal property, please contact our office as special approval will be necessary. Local authorities will use the box below for “approval” stamps or seals, such as the City of Chicago Liquor Commission; if not applicable, ATTACH a photocopy of the approval letter or certificate. ATTACH: LOCAL AUTHORITY APPROVAL or (IF MISSING, APPLICATION WILL BE REJECTED) Local Liquor Commissioner’s Event Approval Stamp Here ( if applicable ) 8. DRAM SHOP INSURANCE You MUST submit proof that Dram Shop insurance to the maximum limit has been secured for this event. ATTACH a photocopy of the insurance rider to this application. Remember, it must cover the LOCATION where the special event is being held and the coverage must COINCIDE WITH THE DATES OF THE EVENT. ATTACH: DRAM SHOP INSURANCE RIDER (IF MISSING, APPLICATION WILL BE REJECTED) 9. PAYMENT Determine the payment amount for your application(s). For efficiency, you may group multiple applications and submit a single check to cover all events. Make your check or money order payable to the Illinois Liquor Control Commission. 10. LATE FILING FEE If you expect that your application(s) will not arrive at Commission premises within the required 14-day advance notice period, submit an additional $25.00 late fee for EACH application. If late fee is missing, application(s) will be rejected. 11. SIGNATURE/DATE/TITLE The application must be signed and dated by the applicant or an authorized agent of the applicant along with the title/position of the person signing. The signature must be an original (do not send in a copied or faxed form). 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 THE COMMISSION WITHIN 30 WORKING DAYS OF CHANGES IN ANY OF THE ABOVE INFORMATION. SIGNATURE OF APPLICANT/AUTHORIZED AGENT IL 567-0028 (07/2005) TITLE/POSITION Printed on Recycled Paper DATE Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com