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Data Request Form - Illinois

Data Request Form Form. This is a Illinois form and can be used in Liquor Control Commission Statewide .
 Fillable pdf Last Modified 3/21/2011
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State of Illinois Liquor Control Commission Governor Pat Quinn g Acting Chairman Stephen Schnorf DATA REQUEST FORM Contact: Illinois Department of Revenue FOIA Officer Tel: (217) 782-0985 g Fax: (217) 524-3402 _____________________________________________ _____________________________ ________________________ Requestor's Name, Firm or Other Affiliation Requestor's Street Address Contact Name Telephone _____________________________________________ _____________________________ City, State, Zip Code ________________________ Date of Request DATA FIELD INFORMATION: CORPORATION (Check all boxes to be included on the requested report) STATE LICENSE LOCAL LICENSE DOING BUSINESS AS (D/B/A) 9 Corporate name 9 Corporate Address 9 Illinois Business Tax (IBT) Number 9 D/B/A Name 9 D/B/A Address 9 D/B/A Telephone 9 D/B/A County 9 Retail Type (On/Off Premises) 9 License number 9 License Class 9 Issue Date 9 Expiration Date 9 Local License Number 9 Local License Issue Date 9 Local License Expiration 9 License Licensing Authority (Municipality/County) DATA SELECTION CRITERIA : (If requesting multiple zip codes, cities, or counties, attach a separate sheet as needed.) STATUS: Active Licensees _____ OR issued dates from _______________________ to ___________________________ ZIP CODE(S): ____________________ CITY(S) _________________________ COUNTY(S) __________________________ LICENSE CLASS: MANUFACTURERS (Check all boxes to be included on the requested report) DISTRIBUTORS RETAILERS OTHERS 9 Distiller 9 Distributor 9 Rectifier 9 Distributor/Importing Distributor 9 Brewer 9 Distributor/Importing Distributor/ 9 Wine Maker (1st Class) Foreign Importing Distributor 9 Wine Maker (2nd Class) 9 Limited Wine Manufacturer 9 Wine Manufacturer (1st Class) 9 Wine Manufacturer (2nd Class) 9 On Premises Retailer 9 Off Premises Retailer 9 Combined Retailer 9 Wine Maker Retailer 9 Brew Pub 9 Caterer 9 Auction 9 Non-Beverage Users 9 Non-Resident Dealers 9 Airplane 9 Boat 9 Railroad 9 Broker Winery Shipper's DATA SORTING SEQUENCE: (If Name is selected you must indicate if it is Corporate Name or D/B/A Name.) PRIMARY SORT FIELD: _____________________________ SECONDARY SORT FIELD: _________________________ 9 Ascending (Z - A) 9 Descending (A - Z) ELECTRONIC DATA SELECTION FORMAT: 9 Data - DBF/FoxPro 9 Data - DBF/FoxPlus 9 Spreadsheet - Excel (XLS)* 9 Mail Merge (Generic Word Processing) DELIVERY CRITERIA: MEDIA SELECTION (Small data requests only indicated with *) 9 ASCII SDF (Fixed Length) 9 ASCII Delimited (Standard) 9 Mail Merge (Microsoft Word) 9 9 (Small data requests only indicated with *) FREQUENCY OF RECEIPT REQUESTED DELIVERY DATE 9 Printed Report* 9 Electronic File Transfer: 9 CD - ROM 9 One-Time Request 9 Yearly 9 Quarterly 9 Monthly 9 ASAP 9 End of Month 9 End of Week 9 Other: __________________________9 Email address (for electronic file) Please allow for additional time for the production of large data requests. The Commission cannot be responsible for any loss of data occurring in transit. For non-technical assistance with your request, please contact the Illinois Department OfRevenue Freedom of Information Officer at the number provided toward the the top of the page. Email request to: REV.FOIA@illinois.gov (Or mail to: Illinois Dept. of Revenue FOIA Officer, 101 W. Jefferson St, MC 6-595, Springfield, IL 62702) American LegalNet, Inc. www.FormsWorkFlow.com
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