Fillable Il-Elf Application Form printable pdf download

Il-Elf Application Form

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This space for use by

IL-ELF Application

Secretary of State.

Fax completed form to:

You must complete this form to

participate in the IL-ELF program.

Secretary of State

Department of Business Services

❒ New Application

217-558-0076 (fax)

❒ Update _______________________

IL-ELF Number

1. Applicant/Firm Name

________________________________________________________________________________________

2. Address

____________________________________________________________________________________________________

Street

______________________________________________________________________________________________________________

City, State, ZIP Code

3. Phone Number

______________________________________________________________________________________________

4. Fax Number (required)

________________________________________________________________________________________

5. Contact Person

_____________________________________________________________________________________________

6. E-mail Address

Phone Number

__________________________________________

_____________________________________

7. Method of Payment (Select Electronic Fund Transfer or Credit Card)

❒

Electronic Fund Transfer:

Checking Account

Savings Account

Routing Number

Account Number

___________________________________

❒

Credit Card:

Visa

Discover

Mastercard

American Express

Card Number

Expiration Date

_____________________________________________

________________________________

Name on Card

___________________________________________________________________________________________

Cardholder’s Billing Address

________________________________________________________________________________

Street

_________________________________________________________________________________________________________

City, State, ZIP Code

Printed by authority of the State of Illinois. C-328.1 — web — February 2006

Il-Elf Application Form

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