2.
STATUS OF BUSINESS
Check the applicable box (sole proprietorship, partnership, Illinois corporation, foreign corporation, or limited liability company) which
corresponds to your business’ official papers filed with the Office of the Illinois Secretary of State.
Based on the box that you check, provide: the date of the filing of the sole proprietorship with the county clerk; in the case of a partnership,
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; or in the case of a limited liability company, the date of formation of such entity.
Note:
In the case of a sole proprietorship, Section 5/6-2 of the Illinois Liquor Control Act requires that the
business owner reside within the jurisdiction that grants the local liquor license. Drivers License copy required.
A.
C.
D.
E.
B.
Sole Proprietorship
Partnership
Illinois Corporation
Foreign Corporation
Limited Liability Company
3.
OWNERSHIP INFORMATION
Provide the owner/ofcer/partner information in accordance with the business status described under Question 2. This information must be
submitted for all owners/ofcers/partners. The same information must be submitted for shareholders with interests equal to or exceeding
ve percent.
The following information must be provided for each individual applicant, sole proprietor, partner, corporate ofcer or director (whether or
not they own any stock), shareholder owning in the aggregate stock equal to or more than ve percent (including ofcers, directors and
shareholders with stock equal to or more than ve percent 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 ve percent interest. All not-
for-prot organizations and associations must provide the requested information for all corporate ofcers, directors and managers.
If additional space is needed, provide information on a separate sheet(s) in the same format as this application. BEFORE COMPLETING
THIS SECTION, CHECK QUESTION NO. 7 - ELIGIBILITY.
For each owner/ofcer/partner/ve percent shareholder, provide full name, home address, city, state, ZIP Code, Social Security number, date
of birth, sex, title/position, home telephone number, and percentage ownership. Total percentage ownership should equal 100 percent. If
there are a number of shareholders owning less than ve percent, indicate the aggregate total of ownership under Line E.
%
E.
Total percentage of all stock held by all persons with less than five percent interest.
IL 567-0015 (1/2019)
PAGE 3 OF 7
Date led with County Clerk:
Date of Formation:
Date of Incorporation:
State of Incorporation:
IL Secretary of State File #:
G.
H.
I.
F.
Not-For-Prot
Government
Receivership
Trust/Estate
Date Qualied to do Business in IL:
A.
B.
C.
D.
( )
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX TITLE/POSITION AREA CODE/HOME TELEPHONE NO.
% OWNED
( )
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX TITLE/POSITION
% OWNED
( )
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX TITLE/POSITION
% OWNED
( )
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX TITLE/POSITION
% OWNED
AREA CODE/HOME TELEPHONE NO.
AREA CODE/HOME TELEPHONE NO.
AREA CODE/HOME TELEPHONE NO.