Fillable Illinois Liquor Control JB Pritzker Commission Governor (Illinois)

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Illinois Liquor Control JB Pritzker Commission Governor (Illinois)

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IL 567-0053 (1/2019)
Illinois Liquor Control
Commission
JB Pritzker
Governor
APPLICATION FOR REGISTRATION
MANUFACTURER’S REGISTERED AGENT
50 W. WASHINGTONST., SUITE 209
CHICAGO, ILLINOIS 60601
TELEPHONE: 312 814-2206
TDD: 312 814-1844
300 W. JEFFERSON ST., SUITE 300
SPRINGFIELD, ILLINOIS 62702
TELEPHONE: 217 782-2136
WEBSITE: ILCC.llinois.gov
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
BUSINESS STREET ADDRESS
CITY
STATE
ZIP CODE
APPLICANT’S NAME Business, Partnership, Corporation)
TYPE OR PRINT INFORMATION
CURRENT LIQUOR LICENSE NO.
APPLICATION DATE
DOING BUSINESS AS (DBA)
BUSINESS TELEPHONE NUMBER
( )
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
MANUFACTURER’S AGENTS
Please list the name, address, phone number and email address of manufacturer’s agent(s) for which identication cards are requested.
For each individual listed, the applicant must attach a statement of representation. Attach additional sheets if necessary.
CONTACT INFORMATION
Provide the contact information for your business. The contact person should be the responsible party we can contact and who can answer questions on
behalf of the business. The mobile or alternate number should be in addition to any business numbers on le. The email address should be the active email
address for the business, not the personal email address of the contact person.
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
PAGE 1 OF 2
Use your 'Mouse' or the 'Tab key' to move through the fields and 'Mouse' or 'Space bar' to enable the checkboxes.
Does the applicant or associate hold any retail alcohol beverage license or any nancial or other interest in such a license
or establishment? If yes, describe and provide current license number: __________________________________
YES
NO
Has the applicant, partners or ofcers ever been convicted of any violation of the Illinois Liquor Control Act of a felony in
this state, any other state, or under federal liquor laws? If yes, please give full details.
YES
NO
PRINT FULL NAME AND TITLE OF APPLICANT
SIGNATURE OF APPLICANT
DATE
NOTE: Identication cards must be obtained for each sales representative employed. Cards expire concurrent with the manufacturer’s liquor license.
IL 567-0053 (1/2019) PAGE 2 OF 2
Illinois Liquor Control
Commission
JB Pritzker
Governor
STATEMENT OF REPRESENTATION
REGISTRATION OF MANUFACTURER’S AGENT
100 W. RANDOLPH ST., SUITE 7-801
CHICAGO, ILLINOIS 60601
TELEPHONE: 312 814-2206
TDD: 312 814-1844
101 W. JEFFERSON ST., SUITE 3-525
SPRINGFIELD, ILLINOIS 62702
TELEPHONE: 217 782-2136
WEBSITE: ILCC.llinois.gov
I, ______________________________________________ as ___________________________________________________
for _________________________________________________________________________________ have a contractual agreement
with ________________________________________________________________________________ to represent and promote our
products. This agreement covers the following territories:
I understand that under Illinois law:
Registration of agents, representatives, or persons acting on behalf of a manufacturer is fullled by submitting a form to the
Commission. The form shall be developed by the Commission and shall include the name and address of the applicant,
the name and address of the manufacturer he or she represents, the territory or areas assigned to sell to or discuss pricing
terms of alcoholic liquor, and any other questions deemed appropriate and necessary. All statements in the forms required
to be made by law or by rule shall be deemed material, and any person who knowingly misstates any material fact
under oath in an application is guilty of a Class B misdemeanor. Fraud, misrepresentation, false statements, misleading
statements, evasions, or suppression of material facts in the securing of a registration are grounds for suspension or
revocation of the registration. (235 ILCS 5/5-1)
SIGNATURE OF MANUFACTURER
TITLE
DATE
NOTE: Identification cards must be obtained for each sales representative employed. Cards expire concurrent with the manufacturer’s liquor license.
IL 567-0053 (1/2019)
NAME TITLE
NAME OF MANUFACTURER
NAME OF MANUFACTURER’S AGENT
SIGNATURE OF MANUFACTURER’S AGENT
SOCIAL SECURITY NUMBER
DATE
DATE OF BIRTH
CONTACT INFORMATION
Provide the contact information for your business. The contact person should be the responsible party we can contact and who can answer questions on
behalf of the business. The mobile or alternate number should be in addition to any business numbers on le. The email address should be the active email
address for the business, not the personal email address of the contact person.
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
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Illinois Liquor Control JB Pritzker Commission Governor (Illinois)

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Completed 9 November 2021

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