Registration Statement (Illinois Compiled Statutes, Chapter 235) TO THE ILLINOIS LIQUOR CONTROL COMMISSION Pursuant to the requirement of Section 5/6-9 of the Illinois Liquor Control Act the undersigned, a (Insert -- Manufacturer, Distributor, Importing Distributor, or Non-resident Dealer) does hereby register with said Commission the following named persons or companies as being the only ones to whom the undersigned has granted the right to sell or distribute at wholesale within the State of Illinois, one or more of those alcoholic liquors which bear trade-marks, brands or names owned or controlled by the undersigned. The undersigned does hereby further register opposite the name of said persons or companies, the respective trademarks, brands or names, owned or controlled by the undersigned, concerning which said persons have been given such distributing rights and the rspective geographical territories for which such distributing rights have been given to said persons or companies, and the period of time for which such rights are granted to such person. NAME, ADDRESS, CITY, STATE AND ZIP CODE OF WHOLESALER TRADE-MARK BRAND, OR NAME OF ITEM GEOGRAPHICAL TERRITORY TIME PERIOD IMPORTANT NOTICE This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the Illinois Liquor Control Act, Ch. 235, Ill. Comp. Stat., 5/ 6-9. Disclosure of this information is MANDATORY. Failure to provide any information will result in nonissuance of your license and/or nonregistration of your products. This form has been approved by the Forms Management Center. IL 567-0014 (01/2006) CORPORATE NAME: ADDRESS: (Street Number) (City or Town) SIGNED BY: (Title) DATE: STATE LICENSE # Printed on Recycled Paper EXP. DATE American LegalNet, Inc. www.FormsWorkflow.com