Form Il 567-0059 - Application For State Of Illinois Non-Resident Dealer'S Liquor License Page 3
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4B. APPLICANT INFORMATION
Applicant is the:
6.
Actual Manufacturer of the products described herein.
Primary United States importer of products described herein which are manufactured outside of the United States
(Provide an appointment letter from the
manufacturer).
Duly registered agent of the manufacturer or duly registered agent of the primary U.S. importer of products de-
scribed herein.
(Provide an appointment letter from the
manufacturer).
List, alphabetically, on separate sheet and attach, all of the alcoholic beverage products for distribution in Illinois, which
7.
(a)
you manufacture, by their full product name as shown on their federally (BATF)approved labels.
(b)
If you are not the actual manufacturer of any given alcoholic beverage product(s) which you distribute for sale within Illinois,
list alphabetically, by manufacturer on a separate sheet, all of the alcoholic beverage products which you distribute as
primary United States importer or duly registered agent.
NOTE: THE ANSWERS TO QUESTIONS 7(a) AND 7(b) DO NOT FULFILL THE SEPARATE REGISTRATION REQUIREMENTS SET
FORTH IN SECTION 5/6-9 OF THE ACT AND SECTION 100.60 OF THE RULES OF THE COMMISSION. THE SAME ARE TO BE
REPORTED ON THE REGISTRATION FORM OF THIS COMMISSION. PRODUCTS NOT SO REGISTERED MAY NOT BE DISTRIB-
UTED IN ILLINOIS EVEN IF A NON-RESIDENT DEALER’S LICENSE IS SECURED. CHANGES IN PRODUCTS LISTED ON THIS
FORM AND ON THE REGISTRATION FORM MUST BE MADE PRIOR TO SHIPMENT OF PRODUCTS INTO ILLINOIS.
Have all Registration Statements required by Section 5/6-9 of the Act and Section 100.60 of the Rules of the Commission been filed
8.
Yes
by the person who owns or controls the brands listed above?
No
9. Has a pre-approved copy of the “BATF Application for Label Approval” been filed for each and every product listed in your answer to
Question #7 and on your Registration Statement(s)?
Yes
No
List the name(s) and address(es) of all Illinois distributors who are currently registered under Section 5/6-9 to distribute these
10.
products. (Attach a separate sheet if needed)
ADDRESS OF ILLINOIS DISTRIBUTOR
NAME OF ILLINOIS DISTRIBUTOR
11. Is the Applicant currently licensed in any capacity, other than a Non-resident Dealer, by this Commission?
Yes
No
If yes, give name of licensee and current State liquor license no.
NAME
CURRENT ILLINOIS LIQUOR LICENSE NO.
12.
Is any subsidiary, affiliate, officer, associate, member, partner, representative, employee, agent, shareholder of the applicant OR the
manufacturer for whom you act as primary United States importer or agent OR is the manufacturer itself currently licensed in any
capacity, other than a Non-resident Dealer, by this Commission?
If yes, give name(s) of licensee(s) and
Yes
No
current State liquor license no.(s). (Attach additional sheet(s), if necessary)
NAME
CURRENT ILLINOIS LIQUOR LICENSE NO.
NAME
CURRENT ILLINOIS LIQUOR LICENSE NO.
IL 567-0059 (03/2006)
Page 3 of 4
Printed on Recycled Paper
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