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Illinois Liquor Control Pat Quinn Commission Governor (Albany High School)

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APPLICATION FOR STATE OF ILLINOIS
NON-RESIDENT DEALER’S LIQUOR LICENSE
DEFINITIONS
A Non-resident Dealer’s license shall permit such licensee to ship into and warehouse alcoholic liquor in this State from any point outside
of this State, and to sell such alcoholic liquor to Illinois-licensed foreign importers and importing distributors and to no one else in this
State; provided that said Non-resident Dealer shall register with the Illinois Liquor Control Commission each and every brand of alcoholic
liquor which it proposes to sell to Illinois licensees during the license period; and further provided that it shall comply with all of the
provisions of Section 6-9 of the Liquor Control Act with respect to registration of such Illinois licensees as may be granted the right to sell
such brands at wholesale. Please note that you must appoint an Illinois-licensed distributor (see page 3).
Page 1 of 4
IL 567-0059 (03/2006)
Printed on Recycled Paper
IMPORTANT NOTICE: THE ILLINOIS LIQUOR CONTROL COMMISSION IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY UNDER THE ILLINOIS LIQUOR CONTROL ACT
(235 ILCS 5/1 ET SEQ.). DISCLOSURE OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE ANY INFORMATION WILL RESULT IN THE NON-ISSUANCE OF YOUR LICENSE. FORM
APPROVED BY THE STATE FORMS MANAGEMENT CENTER.
Please include the following REQUIRED supporting documents:
If you have agents, representatives or persons acting on your behalf in Illinois that sell or discuss pricing terms of alcoholic liquor
you are required to register each of these individuals by submitting forms IL 567-0053 “Application for Registration - Manufacturer’s
Registered Agent”, and IL 567-0054 “Statement of Representation - Registration of Manufacturer’s Agent”.
Currently licensed Illinois manufacturer - Class 1- Distiller, Class 2- Rectifier, or Class 3-Brewer.
Non-resident dealer who is a manufacturer of less than 500,000 gallons per year combined plant total, or agent
thereof AND/OR Primary U.S. Importer exporting less than 500,000 gallons into Illinois yearly, or agent thereof.
Non-resident dealer who is a manufacturer of 500,000 gallons or more per year combined plant total, or agent
thereof AND/OR primary U.S. importer exporting 500,000 gallons or more into Illinois yearly, or agent thereof.
FEE: $270.00
FEE: $90.00
FEE: NONE
Illinois Liquor Control
Commission
Pat Quinn
Governor
100 W. RANDOLPH ST.
SUITE 7-801
CHICAGO, ILLINOIS 60601
TELEPHONE: 312-814-2206
FAX: 312-814-2241
TDD: 312-814-1844
101 W. JEFFERSON ST.
SUITE 3-525
SPRINGFIELD, ILLINOIS 62702
TELEPHONE: 217-782-2136
FAX: 217-524-1911
WEB SITE: www.state.il.us/LCC
• The enclosed Registration Statement;
• The following U.S. Department of the Treasury Tax and Trade Bureau applicaton forms (please visit the
TTB website at
www.ttb.gov or call 1-877-882-3277 or for further information regarding these forms):
a) A copy of the Label Approval. Visit
www.ttb.gov to download the F 5100.31 application form;
b) A copy of the Basic Permit. Visit
www.ttb.gov to download the F 5100.24 application form;
• The
enclosed Schedule L (RL-26-L) from the Illinois Department of Revenue (please call IDOR at
217-785-2622 should you require further assistance);
• The
enclosed Application for Registration – Manufacturer’s Registered Agent (if applicable*);
• The
enclosed Statement of Representation – Registration of Manufacturer’s Agent (if applicable*).
*If you have agents, representatives or persons acting on your behalf in Illinois that sell or discuss pricing terms
of alcoholic liquor, you are required to register each of these individuals by submitting the above two forms.
Use your 'Mouse' or 'Tab key' to move through the fields.
FOR OFFICE
USE ONLY
DATE ISSUED
LICENSE NO.
EXPIRATION DATE
Application for State of Illinois Non-resident Dealer’s Liquor License
CORPORATE/BUSINESS(DBA) INFORMATIONA.
AREA CODE/TELEPHONE NUMBER
EXT.
Page 2 of 4
IL 567-0059 (03/2006)
Printed on Recycled Paper
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
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.
1. FEIN
FEIN #
CHIEF OPERATING ADDRESS
4.
Enter the street address, city, state, and Zip Code of the corporation, partnership, etc..
ADDRESS
CITY
STATE
ZIP CODE
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
Enter the telephone number for the corporation, partnership, etc.
PHONE NUMBER
2.
ILLINOIS BUSINESS TAX # (DO NOT FILL IN SPACE BELOW)
B.
APPLICANT INFORMATION
6.
Applicant is the:
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.
10.
12.
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.
7. (a)
List, alphabetically, on separate sheet and attach, all of the alcoholic beverage products for distribution in Illinois, which
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.
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)?
List the name(s) and address(es) of all Illinois distributors who are currently registered under Section 5/6-9 to distribute these
products. (Attach a separate sheet if needed)
11.
Is the Applicant currently licensed in any capacity, other than a Non-resident Dealer, by this Commission?
If yes, give name of licensee and current State liquor license no.
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
current State liquor license no.(s). (Attach additional sheet(s), if necessary)
NAME CURRENT ILLINOIS LIQUOR LICENSE NO.
NAME CURRENT ILLINOIS LIQUOR LICENSE NO.
NAME CURRENT ILLINOIS LIQUOR LICENSE NO.
Page 3 of 4
IL 567-0059 (03/2006)
Printed on Recycled Paper
NAME OF ILLINOIS DISTRIBUTOR
ADDRESS OF ILLINOIS DISTRIBUTOR
8.
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
by the person who owns or controls the brands listed above?
Ye s
No
Ye s
No
Ye s
No
Ye s
No
(Provide an appointment letter from the manufacturer).
Actual Manufacturer of the products described herein.
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.
Page 4 of 4IL 567-0059 (03/2006)
Printed on Recycled Paper
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.
13.
If applicant warehouses liquor in Illinois, give address
NAME
B.
APPLICANT INFO ( cont’d.)
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX TITLE/POSITION AREA CODE/TELEPHONE NO.
% OWNED
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX TITLE/POSITION AREA CODE/TELEPHONE NO.
% OWNED
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX TITLE/POSITION AREA CODE/TELEPHONE NO.
% OWNED
OWNERSHIP INFORMATION
C.
14. Name/Title/Phone No. of person completing this application.
ADDRESS CITY STATE
ZIP CODE
COUNTY
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:
Signature of Applicant or Authorized Agent
Signature of Applicant or Authorized Agent
Title or Position
Title or Position
Date Signed
Date Signed
TITLE
TELEPHONE NO.
TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% INTEREST
%
a.
b.
c.
d.
Registration Statement
(Illinois Compiled Statutes, Chapter 235)
TO THE ILLINOIS LIQUOR CONTROL COMMISSION
Pursuant to the requirement of Section 5/6-9 of the Illinois Liquor Control Act the undersigned, a
(Insert -- Manufacturer, Distributor, Importing Distributor, or Non-resident Dealer)
does hereby register with said Commission the following named persons or companies as being the only ones to whom the
undersigned has granted the right to sell or distribute at wholesale within the State of Illinois, one or more of those alcoholic
liquors which bear trade-marks, brands or names owned or controlled by the undersigned. The undersigned does hereby further
register opposite the name of said persons or companies, the respective trademarks, brands or names, owned or controlled by
the undersigned, concerning which said persons have been given such distributing rights and the rspective geographical
territories for which such distributing rights have been given to said persons or companies, and the period of time for which such
rights are granted to such person.
NAME, ADDRESS, CITY, STATE AND
ZIP CODE OF WHOLESALER
TRADE-MARK BRAND, OR
NAME OF ITEM
GEOGRAPHICAL
TERRITORY
TIME
PERIOD
CORPORATE NAME:
ADDRESS:
SIGNED BY:
DATE:
STATE LICENSE #
EXP. DATE
(Street Number)
(City or Town)
(Title)
Printed on Recycled Paper
IL 567-0014 (01/2006)
This state agency is requesting disclosure of infor-
mation that is necessary to accomplish the statutory
purpose as outlined under the Illinois Liquor Control
Act, Ch. 235, Ill. Comp. Stat., 5/6-9. Disclosure of this
information is MANDATORY.
Failure to provide any information will result in
nonissuance of your license and/or nonregistration of
your products. This form has been approved by the
Forms Management Center.
IMPORTANT NOTICE
Illinois Department of Revenue
Page ____ of ____
RL-26-L Schedule L
Out-of-state Sellers’ Shipment Report
Read this information first
Make a copy of this schedule before completion if you need to report more than provided for here. After you have
completed your schedule(s), make a photocopy and retain the copy for your records.
Step 1: Identify your business and your type of transaction
a Name:_______________________________________________ Illinois Business Tax number (IBT no.): __ __ __ __ __ __ __ __
Address:_____________________________________________ Federal Employer Identification number: ____ _______________
Number and street (FEIN)
__________________________________________________ Tax period: __ __ __ __ __ __
City State/Providence ZIP Month Year
Country/Territory:___________________________ Telephone: ______________________ Ext: __________
b Check here if you had no shipments to report during this tax period.
Step 2: Tell us about the alcoholic liquors you shipped into Illinois
Equivalent in wine gallons
Invoice no. Account no. of Name and complete address of
Cider 0.5 % Alcohol 14 % Alcohol > 14% Alcohol 20%
and date whom you sold and whom you sold and shipped to to 7% or beer or less and < 20% or more
shipped to
____________ ___________ ________________________________________________________ __________ __________ __________
_ _ _ _ _ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ________________________________________________________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ________________________________________________________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ________________________________________________________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ________________________________________________________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ________________________________________________________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ________________________________________________________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
Page subtotal _________ __________ _________ _________
Grand total _________ __________ _________ _________
(See instructions.)
RL-26-L (R-04/06)
IL-492-1493
RL-26-L (R-04/06)
Schedule L Instructions
General Information
Who must file this schedule?
You must file Schedule L, Out-of-state Sellers’ Shipment
Report, if you are a seller located outside of Illinois and make
shipments of alcoholic liquors into Illinois.
When and where do I file Schedule L?
You must file Schedule L on or before the fifteenth day of each
month for the preceding month.
Note: You must file Schedule L even if you made no ship-
ments during the reporting period.
Mail your completed schedule to
LIQUOR AND CIGARETTE TAX SECTION
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19477
SPRINGFIELD IL 62794-9477
What if I need assistance?
If you have questions about Schedule L, call our Springfield
office weekdays from 8:00 a.m. to 4:30 p.m. at 217 785-2622
or write to us at the address listed above.
Step-by-Step Instructions
Step 1: Identify your business and type of
transaction
a Write your business’ name, address, and Illinois Business
Tax number (IBT no.) that has been issued to you by us.
Also, tell us your Federal Employer Identification number
(FEIN) and the tax period for which you are filing this
schedule.
b Check here if you had
no
shipments to report during this
reporting period.
Step 2: Tell us about the alcoholic liquors you
shipped into Illinois
You must provide invoice number (include the invoice date)
and purchasers’ account number.
Tell us the name and address of whom you sold or shipped
the alcoholic liquors you are reporting.
Report the total actual wine gallonage equivalent for each
class of alcoholic liquor per invoice number.
Grand total:
• If you are filing only one page, copy the “Page subtotal”
amounts to the “Grand total” lines.
• If you are filing multiple pages, add all “Page subtotals”
together for each liquor class and write each sum on the
appropriate “Grand total” line on the last page.
This form is authorized by the Liquor Control Act of 1934. Disclosure of this information is REQUIRED. Failure to provide
information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-1493
APPLICATION FOR REGISTRATION
MANUFACTURER’S REGISTERED AGENT
CURRENT LIQUOR LICENSE NO.
TYPE OR PRINT INFORMATION
APPLICANT’S NAME (Business, Partnership, Corporation)
APPLICATION DATE
DBA OR TRADE NAME
BUSINESS PHONE
BUSINESS STREET ADDRESS
CITY
STATE
ZIP
NAME, ADDRESS, PHONE OF MANUFACTURER’S AGENT(S) FOR WHICH IDENTIFICATION CARD IS REQUESTED. FOR EACH INDI-
VIDUAL LISTED, THE APPLICANT MUST ATTACH A STATEMENT OF REPRESENTATION.
ATTACH ADDITIONAL SHEETS, IF NECESSARY.
NAME
PHONE
ADDRESS, CITY, STATE, ZIP CODE
NAME
PHONE
ADDRESS, CITY, STATE, ZIP CODE
NAME
PHONE
ADDRESS, CITY, STATE, ZIP CODE
DOES THE APPLICANT OR ASSOCIATE HOLD ANY RETAIL ALCOHOL BEVERAGE LICENSE, OR ANY FINANCIAL OR OTHER INTEREST
IN SUCH A LICENSE OR ESTABLICHMENT?
IF YES, DESCRIBE AND PROVIDE CURRENT LICENSE NUMBER.
HAS THE APPLICANT, PARTNERS OR OFFICERS, EVER BEEN CONVICTED OF ANY VIOLATION OF THE ILLINOIS LIQUOR CONTROL ACT OR
A FELONY IN THIS STATE, ANY OTHER STATE, OR UNDER FEDERAL LIQUOR LAWS?
PRINT FULL NAME AND TITLE OF APPLICANT
SIGNATURE OF APPLICANT DATE
IF YES, GIVE FULL DETAILS.
IDENTIFICATION CARDS MUST BE OBTAINED FOR EACH SALES REPRESENTATIVE EMPLOYED.
CARDS EXPIRE CONCURRENT WITH MANUFACTURER’S LIQUOR LICENSE.
NOTE:
Printed on Recycled Paper
IL 567-0053 (10/2005)
NO
YES
NO
YES
State of Illinois
LIQUOR CONTROL COMMISSION
100 WEST RANDOLPH, SUITE 7-801, CHICAGO, IL 60601
PH: 312-814-2206 FAX: 312-814-2241 TDD (312) 814-1844
State of Illinois
LIQUOR CONTROL COMMISSION
100 WEST RANDOLPH, SUITE 7-801, CHICAGO, IL 60601
PH: 312-814-2206 FAX: 312-814-2241 TDD (312) 814-1844
STATEMENT OF REPRESENTATION
REGISTRATION OF MANUFACTURER’S AGENT
I
as
for
have a contractual
agreement with
to represent and promote our products. This agreement covers the follwing territory(ies):
I understand that under Illinois Law:
Registration of agents, representatives, or persons acting on behalf of a manufacturer is fulfilled 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 mate-
rial 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’s Agent
Social Security Number
Date of Birth
Date
Signature of Manufacturer Title
Date
Printed on Recycled Paper
IL 567-0054 (10/2005)
(Name)
(Title)
(Name of Manufac-
turer)
(Name of Manufacturer’s
Agent)
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Illinois Liquor Control Pat Quinn Commission Governor (Albany High School)

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