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Application For State Of Illinois BASSET License IL 567-0061 - Illinois
| Application For State Of Illinois BASSET License Form. This is a Illinois form and can be used in Liquor Control Commission Statewide . |
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Illinois Liquor Control Commission Rod R. Blagojevich Governor 100 W. RANDOLPH ST. SUITE 7-801 CHICAGO, ILLINOIS 60601 TELEPHONE: 312-814-2206 FAX: 312-814-2241 TDD: 312-814-1844 101 WEST JEFFERSON SUITE 3-525 SPRINGFIELD, ILLINOIS 62702 TELEPHONE: 217-782-2136 FAX: 217-524-1911 WEB SITE: www.state.il.us/LCC APPLICATION FOR STATE OF ILLINOIS B.A.S.S.E.T. LICENSE In accordance with 77 Illinois Administrative Code, Chapter XVI, Part 3500, the Illinois Liquor Control Commission is authorized to license and regulate persons who operate Beverage Alcohol Sellers and Servers Education and Training (BASSET) programs. A BASSET license will permit the licensee to conduct seller/server training of individuals provided that curriculum and testing requirements are met. Renewals will then occur on an annual basis and renewal notices will be sent 6-7 weeks in advance of license expiration. DOCUMENTS REQUIRED: A copy of training curriculum. A copy of the certificate of course completion. A copy of the pre- and post-tests given to course participants. A copy of any instrumental materials used in the course. If the applicant is a corporation, proof from the Secretary of State of Illinois that the applicant is registered to do business in Illinois and is in good standing. All applicants for licensing as a BASSET program must complete this application form. Respond to all questions on the application and furnish all required supporting documents. Failure to do so will result in the rejection of the application. BASSET LICENSE FEE $250.00 Make check or money order payable to the Illinois Liquor Control Commission. The Commission does not accept U.S. currency/cash as payment. Please print or type the information requested in the spaces provided. The application form must bear an original signature. 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. IL 567-0061 (03/2006) Printed on Recycled Paper PAGE 1 OF 5 American LegalNet, Inc. www.FormsWorkflow.com FOR OFFICE USE ONLY LICENSE NO. DATE ISSUED EXPIRATION DATE COUNTER ! Application for State of Illinois BASSET License 1. APPLICANT - CORPORATE INFORMATION ! A. If you want your renewal application, your license certificate, and other ILCC correspondence sent to your "corporate" address, please check the box to the left. FEIN Enter your Federal Employer Identification Number (FEIN) or Social Security Number 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. FEIN # or SOCIAL SECURITY NO. B. ILLINOIS BUSINESS TAX NUMBER (IBT OR SALES TAX NO.) Enter the eight-digit Illinois Department of Revenue Business Tax (Sales Tax) Number. If you are an established corporation, you must have this number in order for a license to be issued. If you need to obtain this number, call the Illinois Department of Revenue in Chicago at 312814-5258 or in Springfield at 217-785-2889. ILLINOIS BUSINESS TAX # C. TELEPHONE Enter the area code/telephone number/extension of the corporation, partnership, etc. AREA CODE/TELEPHONE NO. ( D. ) COUNTY EXT. Enter the county where the corporation, partnership, etc. is located. COUNTY E. NAME Enter the name of the sole proprietorship (assumed name), partnership, corporation (Illinois, national, or foreign), or limited liability company in this box. Note: this name must be consistent with the name printed on your Illinois Department of Revenue Sales Tax Registration Certificate. CORPORATE NAME DBA NAME F . ADDRESS ADDRESS CITY STATE ZIP CODE Enter the street address, city, state, and Zip Code of the corporation, etc. IL 567-0061 (03/2006) PAGE 2 OF 5 American LegalNet, Inc. www.FormsWorkflow.com 2. STATUS OF BUSINESS Check the applicable box (assumed name/sole proprietorship, partnership, Illinois corporation, foreign corporation, limited liability company) which corresponds to your business' official papers filed with the Office of the Secretary of State. Based on the box that you check, provide the date of the filing of the sole proprietorship/assumed name with the county clerk; in the case of a copartnership, the date of formation of the partnership; in the case of an Illinois corporation, the date of its incorporation; in the case of a foreign corporation, the foreign state where it was incorporated and the date, as well as the date of its becoming qualified under the "Business Corporation Act of 1983" to transact business in the State of Illinois; in the case of a limited partnership, the date of formation of such partnership; or in the case of a limited liability company, the date of formation of such entity. A. B. C. D. E. ! ! ! ! ! Sole Proprietorship Partnership Illinois Corporation Foreign Corporation Limited Liability Company Date Filed With County Clerk: Date Of Formation: Date Of Incorporation: State Of Incorporation: Date Formed: Date Qualified To Do Business In Illinois: 3. OWNERSHIP INFORMATION Provide the owner/officer/partner information in accordance with the business status described under Question 2. This information must be submitted for all owners/officers/partners. The same information must be submitted for shareholders with interests equal to or exceeding 5%. The following information must be provided for each individual applicant, sole proprietor, partner, corporate officer or director (whether or not they own any stock), shareholder owning in the aggregate stock equal to or more than 5%, (including officers, directors and shareholders with stock equal to or more than 5% for all corporate shareholders), and/or manager or agent conducting the business. Indicate the total percentage of stock of the corporation, if any, which is held by persons who hold less than a 5% interest. All not-for-profit organizations and associations must provide the requested information for all corporate officers, directors and managers. If additional space is needed, provide information on a separate sheet(s) in
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