Form Pt-8 - Application For Pull Tab Manufacturer'S Or Supplier'S License - Illinois Department Of Revenue
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3Illinois Department of Revenue
PT-8
Application for Pull Tab
Manufacturer’s or Supplier’s License
License no. ____________________
License issued _________________
Step 1: Check the type of license for which you are applying
Do not write above this line.
Manufacturer
Supplier
Step 2: Identify your business
List all of the following numbers that your business has
been assigned.
Business name __________________________________________
IBT no. ____ ____ ____ ____ - ____ ____ ____ ____
Physical address _________________________________________
FEIN
____ ____ - ____ ____ ____ ____ ____ ____ ____
Number and street
Bingo license no.
B -
_________________
_________________________________________________________
Bingo provider’s license no.
BP - _________________
City
State
ZIP
Bingo supplier’s license no.
BS - _________________
( _____ ) ______________________
________________________
Charitable game license no.
CG - _________________
County
Telephone number
Charitable game provider’s license no.
CP - _________________
Mailing address __________________________________________
Charitable game supplier’s license no.
CS - _________________
Number and street or post office box
Pull tab license no.
P -
_________________
_______________________________________________________
Pull tab supplier’s license no.
PS - _________________
City
State
ZIP
Pull tab manufacturer’s license no.
PM - _________________
Step 3: Tell us about your business
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Check your type of business ownership.
Are you doing business under an assumed name?
Individual
Partnership
Corporation
yes
no
Other (please specify) ______________________________
If “yes” and you are an individual, a partnership, or an other entity,
If you are a corporation, attach your articles of incorporation and
write the county and number of your Assumed Name Certificate.
bylaws. If this is a renewal application, attach these items only if
County_______________________
Number ______________
they have changed since your last application.
If “yes” and you are a corporation, attach a certified copy of your
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When and where was your business established?
Certificate of Registration.
Date __ __/__ __/__ __ __ __
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City _________________________ State ________________
Are you a manufacturer who uses a logo on your pull tabs?
yes
no
3
Are you a foreign corporation?
yes
no
If “yes,” attach a copy of your logo. If this is a renewal
If “yes,” when did you qualify to do business in Illinois?
application, attach your logo only if it has changed since your last
Date __ __/__ __/__ __ __ __
application.
Step 4: Identify your director, officers, partners, and stockholders
If your business is owned or operated by another entity, you must also identify the director, officers, partners, and stockholders
of that entity. Attach additional sheets if necessary. If you are a partnership or a corporation, you must report to us in writing
within 30 days any change in the number or identity of persons owning at least 10 percent of the shares in your business or an
entity that owns or operates your business.
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_______________________________
_____________________________
__ __ __ - __ __ -__ __ __ __
__ __/__ __/__ __ __ __
Name (include middle initial)
Title (if applicable)
Social Security number
Date of birth
_______________________________
____________________________________________________________
______________
Street address
City
State
ZIP
Race*
2
_______________________________
_____________________________
__ __ __ - __ __ -__ __ __ __
__ __/__ __/__ __ __ __
Name (include middle initial)
Title (if applicable)
Social Security number
Date of birth
_______________________________
____________________________________________________________
______________
Street address
City
State
ZIP
Race*
3
_______________________________
_____________________________
__ __ __ - __ __ -__ __ __ __
__ __/__ __/__ __ __ __
Name (include middle initial)
Title (if applicable)
Social Security number
Date of birth
_______________________________
____________________________________________________________
______________
Street address
City
State
ZIP
Race*
* A — Asian or Pacific Islander; B — Black; I — American Indian or Alaskan Native; W — White; or O — Other
PT-8 (R-3/96)
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