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Data Request Form. This is a Illinois form and can be use in Liquor Control Commission Statewide.
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Tags: Data Request Form, Illinois Statewide, Liquor Control Commission
State of Illinois Liquor Control Commission
Governor Pat Quinn g Acting Chairman Stephen Schnorf
DATA REQUEST FORM
Contact: Illinois Department of Revenue FOIA Officer
Tel: (217) 782-0985 g Fax: (217) 524-3402
_____________________________________________
_____________________________
________________________
_____________________________________________
_____________________________
________________________
Requestor’s Name, Firm or Other Affiliation
Contact Name
Requestor’s Street Address
DATA FIELD INFORMATION:
City, State, Zip Code
Telephone
Date of Request
(Check all boxes to be included on the requested report)
CORPORATION
DOING BUSINESS AS (D/B/A)
STATE LICENSE
LOCAL LICENSE
9 Corporate name
9 Corporate Address
9 Illinois Business Tax
9 D/B/A Name
9 D/B/A Address
9 D/B/A Telephone
9 D/B/A County
9 Retail Type (On/Off Premises)
9 License number
9 License Class
9 Issue Date
9 Expiration Date
9 Local License Number
9 Local License Issue Date
9 Local License Expiration
9 License Licensing Authority
(IBT) Number
(Municipality/County)
DATA SELECTION CRITERIA : (If requesting multiple zip codes, cities, or counties, attach a separate sheet as needed.)
STATUS:
Active Licensees _____ OR issued dates from _______________________ to ___________________________
ZIP CODE(S): ____________________ CITY(S) _________________________ COUNTY(S) __________________________
LICENSE CLASS:
(Check all boxes to be included on the requested report)
MANUFACTURERS
DISTRIBUTORS
RETAILERS
9 Distiller
9 Distributor
9 Rectifier
9 Distributor/Importing Distributor
9 Brewer
9 Distributor/Importing Distributor/
9 Wine Maker (1st Class)
Foreign Importing Distributor
9 Wine Maker (2nd Class)
9 Limited Wine Manufacturer
9 Wine Manufacturer (1st Class)
9 Wine Manufacturer (2nd Class)
DATA SORTING SEQUENCE:
OTHERS
9 On Premises Retailer
9 Off Premises Retailer
9 Combined Retailer
9 Wine Maker Retailer
9 Brew Pub
9 Caterer
9 Auction
9 Non-Beverage Users
9 Non-Resident Dealers
9 Airplane
9 Boat
9 Railroad
9 Broker
Winery Shipper's
(If Name is selected you must indicate if it is Corporate Name or D/B/A Name.)
PRIMARY SORT FIELD: _____________________________
SECONDARY SORT FIELD: _________________________
ELECTRONIC DATA SELECTION FORMAT:
9 Ascending (Z - A)
9 Descending (A - Z)
(Small data requests only indicated with *)
9 Data - DBF/FoxPro
9 Data - DBF/FoxPlus
9 Spreadsheet - Excel (XLS)*
9 Mail Merge (Generic Word Processing)
9 ASCII SDF (Fixed Length)
9 ASCII Delimited (Standard)
9 Mail Merge (Microsoft Word)
9
9
DELIVERY CRITERIA:
(Small data requests only indicated with *)
MEDIA SELECTION
FREQUENCY OF RECEIPT
REQUESTED DELIVERY DATE
9 Printed Report*
9 Electronic File Transfer:
9 CD - ROM
9 One-Time Request
9 Yearly
9 Quarterly
9 Monthly
9 ASAP
9 End of Month
9 End of Week
9 Other: __________________________9
Email address (for electronic file)
Please allow for additional time for the production of large data requests. The Commission cannot be responsible for any loss of
data occurring in transit. For non-technical assistance with your request, please contact the Illinois Department OfRevenue Freedom
of Information Officer at the number provided toward the the top of the page.
Email request to: REV.FOIA@illinois.gov
(Or mail to: Illinois Dept. of Revenue FOIA Officer, 101 W. Jefferson St, MC 6-595, Springfield, IL 62702)
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