State of Illinois LIQUOR CONTROL COMMISSION NINETY DAY WAIVER APPLICATION FEE: $10.00 PER LOCATION DISPLAY ORIGINAL FORM NEAR STATE LIQUOR LICENSE PLEASE TYPE OR PRINT THE FOLLOWING INFORMATION: PLEASE NOTE: IF REQUEST INVOLVES MULTIPLE LIQUOR LICENSES, A SEPARATE APPLICATION FORM MUST BE SUBMITTED FOR EACH LICENSE. YOU MAY REPRODUCE THIS PAGE FOR ADDITIONAL APPLICATIONS. DATE OF REQUEST STATE LIQUOR LICENSE NUMBER CORPORATE FEIN NUMBER DATE STATE LICENSE ISSUED DATE OF STATE LICENSE EXPIRATION COUNTY ZIP APPLICANT/CORPORATION NAME D/B/A PREMISE ADDRESS CITY TELEPHONE (INCLUDE AREA CODE) CENTRAL BUSINESS LOCATION WHERE INVOICES WILL BE KEPT: NAME OF BUSINESS ADDRESS CITY COUNTY CONTACT PERSON ZIP TELEPHONE (INCLUDE AREA CODE) I, the undersigned applicant or authorized agent thereof, swear or affirm the matters stated in the foregoing application are true and correct, are made upon my personal knowledge and information, are made for the purpose of requesting the State of Illinois to issue the waiver herein applied for and the applicant is qualified and eligible to obtain the waiver applied for. SIGNATURE OF AUTHORIZED AGENT DATE PRINT OR TYPE FULL NAME TITLE MAKE CHECK OR MONEY ORDER PAYABLE TO THE ILLINOIS LIQUOR CONTROL COMMISSION; RETURN CHECK AND COMPLETED FORM TO 100 WEST RANDOLPH, SUITE 7-801, CHICAGO, IL 60601, ATTN: INVESTIGATIONS 90 DAY WAIVER. PLEASE DO NOT SEND CASH. FOR OFFICIAL USE ONLY: DATE RECEIVED PROCESSING FEE REVIEWED BY ! ! APPROVED DENIED IF APPLICATION DENIED, LIST THE REASON(S) FOR DENIAL: APPROVAL SIGNATURE 90-DAY WAIVER FORM (11/2005) DATE APPROVED American LegalNet, Inc. www.FormsWorkflow.com