Form Rc-2 - Cigarette Distributor License Application - Illinois Department Of Revenue Page 3
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4Business name _______________________________
IBT no. __ __ __ __ - __ __ __ __
FEIN __ __ - __ __ __ __ __ __ __
Step 6: Have each person listed in Step 5 complete the following information
(Use Page 4 for additional information, if needed.)
1
Are you a citizen of the United States?
Name _______________________________________________
yes
no
Address _____________________________________________
If you are a naturalized citizen, when and where were you
____________________________________________________
naturalized?
Nature of relationship __________________________________
Date _ _/_ _/_ _ _ _
Date _ _/_ _/_ _ _ _ to _ _/_ _/_ _ _ _
Place _______________________________________________
4
Have you ever been convicted of a felony or otherwise
2
Do you currently have a financial interest in or are you employed
disqualified from receiving a cigarette license in Illinois?
by any other firm or corporation engaged in the cigarette business?
yes
no
yes
no
If “yes,” list each offense and the court of conviction.
If “yes,” write the name and address of the business, the nature of
Offense _____________________________________________
your relationship, and the date your relationship with that busi-
Court of conviction _____________________________________
ness started.
Name _______________________________________________
Offense _____________________________________________
Address _____________________________________________
Court of conviction _____________________________________
____________________________________________________
5
Nature of relationship __________________________________
Has any license previously issued to you by any state or local
Date _ _/_ _/_ _ _ _
authority been suspended or revoked?
yes
no
Name _______________________________________________
If “yes,” write the type of license, the date it was suspended or
Address _____________________________________________
revoked, where it was issued, and the reason for the action.
____________________________________________________
License type _________________________________________
Nature of relationship __________________________________
Date _ _/_ _/_ _ _ _
Date _ _/_ _/_ _ _ _
Place _______________________________________________
Reason for suspension or revocation ______________________
3
Have you ever had a financial interest in or been employed by
____________________________________________________
any other firm or corporation engaged in the cigarette business?
____________________________________________________
yes
no
If “yes,” write the name and address of the business, the nature of
License type _________________________________________
your relationship, and when your relationship was in effect.
Date _ _/_ _/_ _ _ _
Name _______________________________________________
Place _______________________________________________
Address _____________________________________________
Reason for suspension or revocation ______________________
____________________________________________________
____________________________________________________
Nature of relationship __________________________________
____________________________________________________
Date _ _/_ _/_ _ _ _ to _ _/_ _/_ _ _ _
Step 7: Sign below
All questions must be fully answered in order for your
Make your certified check or money order for $250 payable to “Illinois
application to be processed.
Department of Revenue.” Your payment and a bond in the amount of
$2,500 must accompany this application.
Under penalties of perjury, I state that I have examined this
Mail your application and payment to:
application and, to the best of my knowledge, it is true, correct, and
complete. I further authorize the Illinois Department of Revenue to
MISCELLANEOUS TAXES
obtain police records in order to pursue a security check of each
ILLINOIS DEPARTMENT OF REVENUE
corporate officer.
PO BOX 19039
SPRINGFIELD IL 62794-9039
Signature ______________________________________________
or deliver to:
ILLINOIS DEPARTMENT OF REVENUE
Date __ __/__ __/__ __ __ __
101 WEST JEFFERSON ST
SPRINGFIELD IL 62702
Affix your corporate seal here.
If you have questions, call our Springfield office weekdays between
8:00 a.m. and 4:30 p.m. at 217 782-6997
Do not write below this line.
Received __ __/__ __/__ __ __ __
Examined by ___________________
Approved by ___________________
RC-2 (R-5/99)
Page 3 of 4
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