Application Form For State Of Illinois Special Use Permit Liquor License
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1
2
3FOR OFFICIAL USE ONLY
FOR OFFICE
LICENSE NO.
USE ONLY
DATE ISSUED
EXPIRATION DATE
o
COUNTER
Application for State of Illinois Special Use Permit Liquor License
o
1. APPLICANT INFORMATION
Check here, if license and ILCC correspondence should be sent to this address.
Provide your current State of Illinois Retail liquor license number; provide the corporate/organization name;
provide the corporate/organization Federal Employer Identification Number (FEIN); provide your Illinois Depart-
ment of Revenue IBT number (sales tax number); telephone number; provide your corporate/organization mail-
ing address; and county.
STATE LIQUOR LICENSE NO.
NAME
FEDERAL EMPLOYER ID NO.
ILLINOIS BUSINESS TAX #
AREA CODE/TELEPHONE NO.
(
)
ZIP CODE
COUNTY
ADDRESS
CITY
STATE
o
2. BUSINESS PREMISE INFORMATION
Check here, if license and ILCC correspondence should be sent to this address.
Provide business name (Doing Business As/DBA), telephone number, address and county.
Provide the Federal Tax Stamp Document Control Number. This number indicates that the business has been
approved by the Federal Bureau of Alcohol, Tobacco, and Firearms (BATF) to sell alcoholic beverages. This
number can be obtained by calling BATF at (800) 937-8864 or (513) 684-2979.
NAME (DOING BUSINESS AS D/B/A )
AREA CODE/TELEPHONE NO.
(
)
ADDRESS
STATE
COUNTY
CITY
ZIP CODE
FEDERAL TAX STAMP DOCUMENT CONTROL NO.
3. PRIOR LIQUOR LICENSE INFORMATION
Has the organization ever applied for and been denied a liquor license? Yes
If “yes”, provide
A.
No
a complete written explanation of the circumstances on a separate sheet of paper.
Has the organization had any previous Special Use Liquor License suspended or revoked?
B.
Yes
No
If “yes”, provide a complete written explanation of the circumstances on a separate
sheet of paper.
Printed on Recycled Paper
Page 2 of 4
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