State of Illinois LIQUOR CONTROL COMMISSION 100 WEST RANDOLPH, SUITE 7-801, CHICAGO, IL 60601 PH: 312-814-2206 FAX: 312-814-2241 TDD (312) 814-1844 STATEMENT OF REPRESENTATION REGISTRATION OF MANUFACTURER’S AGENT as I (Name) (Title) have a contractual for (Name of Manufacturer) agreement with (Name of Manufacturer’s Agent) to represent and promote our products. This agreement covers the following territory(ies): I understand that under Illinois Law: Registration of agents, representatives, or persons acting on behalf of a manufacturer is fulfilled by submitting a form to the Commission. The form shall be developed by the Commission and shall include the name and address of the applicant, the name and address of the manufacturer he or she represents, the territory or areas assigned to sell to or discuss pricing terms of alcoholic liquor, and any other questions deemed appropriate and necessary. All statements in the forms required to be made by law or by rule shall be deemed material, and any person who knowingly misstates any material fact under oath in an application is guilty of a Class B misdemeanor. Fraud, misrepresentation, false statements, misleading statements, evasions, or suppression of material facts in the securing of a registration are grounds for suspension or revocation of the registration. 235 ILCS 5/5-1 Signature of Manufacturer’s Agent Signature of Manufacturer IL 567-0054 (10/2005) Social Security Number Date of Birth Date Title Date Printed on Recycled Paper American LegalNet, Inc. www.FormsWorkflow.com