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Application For Registration Manufacturers Registered Agent IL 567-0053 - Illinois

Application For Registration Manufacturers Registered Agent Form. This is a Illinois form and can be used in Liquor Control Commission Statewide .
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Illinois Liquor Control Commission 100 W. RANDOLPH ST., SUITE 7-801 CHICAGO, ILLINOIS 60601 TELEPHONE: 312 814-2206 TDD: 312 814-1844 Bruce Rauner Governor 101 W. JEFFERSON ST., SUITE 3-525 SPRINGFIELD, ILLINOIS 62702 TELEPHONE: 217 782-2136 WEBSITE: ILCC.llinois.gov APPLICATION FOR REGISTRATION MANUFACTURER'S REGISTERED AGENT CURRENT LIQUOR LICENSE NO. TYPE OR PRINT INFORMATION APPLICANT'S NAME Business, Partnership, Corporation) APPLICATION DATE DOING BUSINESS AS (DBA) BUSINESS TELEPHONE NUMBER ( BUSINESS STREET ADDRESS CITY ) STATE ZIP CODE 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 file. 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 MANUFACTURER'S AGENTS Please list the name, address, phone number and email address of manufacturer's agent(s) for which identification cards are requested. For each individual listed, the applicant must attach a statement of representation. Attach additional sheets if necessary. CONTACT PERSON'S NAME (First, Last) BUSINESS PHONE NUMBER ALTERNATE PHONE NUMBER (Home, Cell, etc.) ( EMAIL ADDRESS ) ( ( ) ) ) ) ) ) PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com FAX 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 IL 567-0053 (11/2016) YES NO Does the applicant or associate hold any retail alcohol beverage license or any financial or other interest in such a license or establishment? If yes, describe and provide current license number: __________________________________ YES NO Has the applicant, partners or officers 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. PRINT FULL NAME AND TITLE OF APPLICANT SIGNATURE OF APPLICANT DATE NOTE: Identification cards must be obtained for each sales representative employed. Cards expire concurrent with the manufacturer's liquor license. IL 567-0053 (11/2016) PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com Illinois Liquor Control Commission Bruce Rauner Governor 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 STATEMENT OF REPRESENTATION REGISTRATION OF MANUFACTURER'S AGENT I, ______________________________________________ as ___________________________________________________ NAME TITLE for _________________________________________________________________________________ have a contractual agreement NAME OF MANUFACTURER with ________________________________________________________________________________ to represent and promote our NAME OF MANUFACTURER'S AGENT 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 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 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'S AGENT SOCIAL SECURITY NUMBER DATE OF BIRTH DATE SIGNATURE OF MANUFACTURER TITLE DATE 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 file. 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 NOTE: Identification cards must be obtained for each sales representative employed. Cards expire concurrent with the manufacturer's liquor license. IL 567-0053 (11/2016) American LegalNet, Inc. www.FormsWorkFlow.com
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