Request for One-Time Transfer of Alcoholic Liquor Fax detailed inventory along with this request to: 312-814-2241 Attn: Ivan Fernandez. NOTE: If more than 5 pages send via email to ivan.fernandez@illinois.gov (or by regular mail to: ILCC, 100 West Randolph, Suite 7-801, Chicago, IL 60601). To: Illinois Liquor Control Commission From: _______________________________ Fax Number: _______________________________ Phone Number: _______________________________ Date: _______________________________ Reason for Request: ____________________________________________________________ ____________________________________________________________ Pursuant to Section 100.250 of the ILCC Rules and Regulations, please consider this request to allow the one-time transfer of alcoholic liquor between the licensed premises listed below. Attached please find a detailed inventory of the alcoholic liquor products to be transferred. The transfer is scheduled to occur on ___________________. FROM: Store: _______________________________ Store: ____________________________ Address: _____________________________ Address: __________________________ _____________________________________ __________________________________ _____________________________________ __________________________________ STATE LIC. NO.: _____________________ STATE LIC. NO.:__________________ TO: Store: _______________________________ Store: ____________________________ Address: _____________________________ Address: __________________________ _____________________________________ __________________________________ _____________________________________ __________________________________ STATE LIC. NO.: ____________________ STATE LIC. NO.:__________________ American LegalNet, Inc. www.FormsWorkFlow.com