Form Il 567-0059 - Application For State Of Illinois Non-Resident Dealer'S Liquor License Page 2
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1
2
3
4FOR OFFICE
LICENSE NO.
USE ONLY
ILLINOIS BUSINESS TAX # (DO NOT FILL IN SPACE BELOW)
DATE ISSUED
EXPIRATION DATE
Application for State of Illinois Non-resident Dealer’s Liquor License
A.
CORPORATE/BUSINESS(DBA) INFORMATION
1. FEIN
Enter your Federal Employer Identification Number (FEIN) in this box. The FEIN is a nine-digit number issued by the U.S. Internal Revenue Service.
This number is used for verification purposes only. If you do not have an FEIN number, call 1-800-829-3676 for general information on how to apply
and to obtain the forms you will need. NOTE, if you have filed an application for your FEIN number, the Commission will accept your application.
FEIN #
2.
PHONE NUMBER
Enter the telephone number for the corporation, partnership, etc.
AREA CODE/TELEPHONE NUMBER
EXT.
3. CORPORATE NAME (Also list trade or business name, if different from corporate name)
Enter the name of the corporation (Illinois, national, or foreign), partnership or limited liability company in this box.
CORPORATE NAME
DBA NAME
4.
CHIEF OPERATING ADDRESS
Enter the street address, city, state, and Zip Code of the corporation, partnership, etc..
ADDRESS
CITY
ZIP CODE
STATE
5. CONTACT PERSON
List the name and address of the person upon whom all “Service of Process” shall be made on behalf of the applicant and to be
contacted in the event of any other problems or questions (person need not be an Illinois resident).
NAME
ADDRESS
CITY
STATE
ZIP CODE
IL 567-0059 (03/2006)
Page 2 of 4
Printed on Recycled Paper
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