Form Il 567-0059 - Application For State Of Illinois Non-Resident Dealer'S Liquor License Page 4
Download a blank fillable Form Il 567-0059 - Application For State Of Illinois Non-Resident Dealer'S Liquor License in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Il 567-0059 - Application For State Of Illinois Non-Resident Dealer'S Liquor License with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4B. APPLICANT INFO ( cont’d.)
13. If applicant warehouses liquor in Illinois, give address
ZIP CODE
ADDRESS
CITY
STATE
COUNTY
14.
Name/Title/Phone No. of person completing this application.
NAME
TELEPHONE NO.
TITLE
OWNERSHIP INFORMATION
C.
For each owner/officer/partner/5% or greater shareholder, provide the following: full name, home address, city, state, Zip Code, social
security number, date of birth, sex, title/position, home telephone number, and percentage ownership. Percentage ownership should
equal 100%. If there are a number of shareholders owning less than 5%, indicate the aggregate total of ownership under d. below:
a.
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
ZIP
STATE
DATE OF BIRTH
SOCIAL SECURITY NO.
SEX
TITLE/POSITION
AREA CODE/TELEPHONE NO.
% OWNED
b.
NAME (LAST, FIRST, MIDDLE INITIAL)
CITY
ZIP
HOME ADDRESS
STATE
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX
TITLE/POSITION
AREA CODE/TELEPHONE NO.
% OWNED
c.
ZIP
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
DATE OF BIRTH
SOCIAL SECURITY NO.
SEX
TITLE/POSITION
AREA CODE/TELEPHONE NO.
% OWNED
d.
TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% INTEREST
%
AFFIDAVIT
The above information is supplied for the purpose of inducing the Illinois Liquor Control Commission to issue a Non-
resident Dealer’s license to the applicant herein and is true and correct, and made upon my personal knowledge and
information. I further swear or affirm that the applicant will not violate any of the laws of the United States of America or the
State of Illinois, in particular, the Illinois Liquor Control Act, Rules and Regulations, and the civil rights sections thereof.
Signature of Applicant or Authorized Agent
Signature of Applicant or Authorized Agent
Title or Position
Title or Position
Date Signed
Date Signed
NOTE: If the license is to be issued to a partnership, two partners must sign. If the license is to be issued to a corporation, the
president and secretary of the corporation must sign, or duly authorized corporate representative.
IL 567-0059 (03/2006)
Page 4 of 4
Printed on Recycled Paper
ADVERTISEMENT
0 votes
Related Articles
Related forms
Instructions For Application For State Of Illinois Special Event Retailer's Liquor License (not-for-profit) Form Il 567-0028 2000
Financial
Form Il 567-0015-a - Application For State Of Illinois Distributor/ Importing Distributor/foreign Importer Liquor License
Legal
Form Cra - Combined Registration Application For State Of Delaware Business License And/or Withholding Agent - 2000
Financial
Form Cra - Combined Registration Application For State Of Delaware Business License And/or Withholding Agent - Division Of Revenue
Financial
Form Cra - Combined Registration Application For State Of Delaware Business License And/or Withholding Agent
Financial
Form Cra - Combined Registration Application For State Of Delaware Business License And/or Withholding Agent
Financial
Related Categories
Parent category: Financial