Form Pt-8 - Application For Pull Tab Manufacturer'S Or Supplier'S License - Illinois Department Of Revenue Page 3
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1
2
3Step 6: Tell us about people in your organization and others who have an interest
in your business
(Attach additional sheets if necessary.)
1
List the following information for all persons or businesses from whom you will purchase or lease pull tab equipment or supplies.
Name _______________________________________________
Name _______________________________________________
Street address _______________________________________
Street address ________________________________________
City, state, ZIP _______________________________________
City, state, ZIP ________________________________________
Supplier’s license number _______________________________
Supplier’s license number _______________________________
2
Fill in the following information on persons not listed in Step 4 or 5 who have a direct or indirect financial, proprietary, or other interest in
your business, or who have made a loan to you or your business.
Name _______________________________________________
Name _______________________________________________
Street address _______________________________________
Street address ________________________________________
City, state, ZIP _______________________________________
City, state, ZIP ________________________________________
Social Security number __ __ __ - __ __ - __ __ __ __
Social Security number __ __ __ - __ __ - __ __ __ __
Date of birth __ __/__ __/__ __ __ __
Date of birth __ __/__ __/__ __ __ __
Month
Day
Year
Month
Day
Year
Business name _______________________________________
Business name _______________________________________
Relationship ______________
Phone (____)______________
Relationship ______________
Phone (____)______________
Nature of the interest ___________________________________
Nature of the interest ___________________________________
Date interest was acquired __ __/__ __/__ __ __ __
Date interest was acquired __ __/__ __/__ __ __ __
Month
Day
Year
Month
Day
Year
Step 7: Answer the following questions
(Attach additional sheets if necessary.)
1
4
Have you, one of your employees, or anyone listed in Step 4 or
Who is responsible for furnishing records and information about
Step 6, Item 2, been convicted of a felony within the last 10 years
your business?
or a violation of the Criminal Code of 1961, Article 28 (gambling)?
Name _______________________________________________
Phone ( _____ ) __________________
yes
no
2
5
Have you, one of your employees, or anyone listed in Step 4 or
Where are your business’ books and records kept?
Step 6, Item 2, ever been a professional gambler?
Street address ________________________________________
yes
no
City, state, ZIP ________________________________________
If “yes,” please provide details. ___________________________
6
____________________________________________________
List all locations where your equipment is stored.
Street address ________________________________________
3
Do you, one of your employees, or anyone listed in Step 4 or
City, state, ZIP ________________________________________
Step 6, Item 2, have any interest, either direct or indirect, in a
licensee listed in Step 2?
Street address ________________________________________
yes
no
City, state, ZIP ________________________________________
Step 8: Sign below
Under penalties of perjury, I state that I have examined this applica-
Make your certified check or money order for $5,000 payable to
tion and, to the best of my knowledge, it is true, correct, and com-
“Illinois Department of Revenue.” Your payment must accompany
plete. I further certify that I have read and understand the provisions
this application.
of the department’s rules governing manufacturers’ or suppliers’
licenses and licensees including, but not limited to, Sections 432.130
Mail your application and payment to:
and 432.140 concerning licensing, production standards, record
keeping, and reporting requirements; 432.150 concerning ineligibility
OFFICE OF BINGO AND CHARITABLE GAMES
for a license; 432.160 concerning restrictions on the sale of pull tabs;
ILLINOIS DEPARTMENT OF REVENUE
432.180 concerning records and audits; and 432.190 concerning
PO BOX 19480
license revocation.
SPRINGFIELD IL 62794-9480
President’s signature ______________________________________
Date
If you have questions, please call our Springfield office weekdays
between 8 a.m. and 4:30 p.m. at 217 524-4164.
Secretary’s signature ______________________________________
Date
Affix your corporate seal here.
SOY-BASE INK
RECYCLED PAPER
This form is authorized as outlined by the Pull Tabs and Jar Games Act. Disclosure of this information is REQUIRED. Failure to provide information
PT-8 (R-3/96)
could result in this form's not being processed. This form has been approved by the Forms Management Center.
IL-492-2681
Page 3 of 3
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