Pat Quinn Governor Illinois Liquor Control Commission 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 SUITE 3-525 SPRINGFIELD, ILLINOIS 62702 TELEPHONE: 217-782-2136 FAX: 217-524-1911 WEB SITE: www.state.il.us/LCC LICENSING DIVISION ** FOR OFFICIAL USE ONLY ** NEW LICENSE NO. DELINQUENCY AFFIDAVIT DATE ISSUED TYPE OR PRINT INFORMATION APPLICANT’S NAME (Individual or Corporation) BUSINESS PHONE BUSINESS NAME (DBA) BUSINESS STREET ADDRESS CITY STATE ZIP EXPIRATION DATE OF OLD LICENSE EXPIRED LICENSE NUMBER REASON(S) FOR NOT RENEWING ON TIME: I, the applicant, for the above named license, hereby acknowledge my deliquency as indicated on my current application and further state that I was selling and/or offering for sale alcoholic beverages without the benefit of a license from to . PRINT FULL NAME OF APPLICANT IL 567-0051 (11/2005) SIGNATURE OF APPLICANT Printed on Recycled Paper DATE American LegalNet, Inc. www.FormsWorkflow.com