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SIGNATURE OF APPLICANT/AUTHORIZED AGENT
IL 567-0050 (1/2019)
TITLE/POSITION
DATE
Determine the payment amount for your application(s). For efficiency, you may group multiple applications and submit a
single check to cover all events. Make check or money order payable to: ILLINOIS LIQUOR CONTROL COMMISSION.
The Commission does not accept U.S. currency/cash as payment.
8.
PAYMENT
If you expect that your application will not arrive at the Commission office within the required 14-day advance notice, submit
an additional $25.00 late fee for EACH application. If the late fee is not included, the application(s) will be rejected.
9.
LATE FILING FEE
The application must be signed and dated by the applicant or an authorized agent of the applicant along with the title/position of the person signing.
The signature must be an original; rubber stamps, photocopies, or faxed copies are not accepted.
5.
PRIOR LIQUOR LICENSE INFORMATION
10.
SIGNATURE/DATE/TITLE
You MUST submit proof that Dram Shop insurance to the maximum limit has been secured for this event.
Attach a photocopy of the insurance rider to this application. Remember, it must cover the location where the special
event is being held and the coverage must coincide with the dates of the event.
ATTACH:
DRAM SHOP INSURANCE RIDER
(IF MISSING, APPLICATION WILL BE REJECTED)
7.
DRAM SHOP INSURANCE
Local Liquor
Commissioner’s
Event Approval
Stamp Here
( if applicable )
You MUST submit proof of local authority approval for your event. Generally, your local municipality will issue
approval in the form of a letter, a certificate, or a rubber stamp. If the event is taking place in an unincorporated area,
the county will need to provide the approval. If the event is taking place on state or federal property, please contact our
office as special approval will be necessary. Local authorities will use the box below for “approval” stamps or seals,
such as the City of Chicago Liquor Commission. If stamps/seals are not applicable, attach a photocopy of the approval
letter or certificate.
ATTACH:
LOCAL AUTHORITY APPROVAL
(IF MISSING, APPLICATION WILL BE REJECTED)
6. LOCAL AUTHORITY APPROVAL
or
A.
B.
If “yes,” provide a complete written explanation of the circumstances on a separate sheet of paper.
Has the organization had any previous liquor license suspended or revoked?
Yes
No
Has the organization ever applied for and been denied a liquor license?
Yes
No
If “yes,” provide a complete written explanation of the circumstances on a separate sheet of paper.
I, THE UNDERSIGNED APPLICANT OR AUTHORIZED AGENT THEREOF, SWEAR OR AFFIRM THAT: THE MATTERS STATED IN THE FORE-
GOING APPLICATION ARE TRUE AND CORRECT; THEY ARE MADE UPON MY PERSONAL KNOWLEDGE AND INFORMATION; THEY ARE
MADE FOR THE PURPOSE OF REQUESTING THE STATE OF ILLINOIS TO ISSUE THE LICENSE HEREIN APPLIED FOR; THE APPLICANT IS
QUALIFIED AND ELIGIBLE TO OBTAIN THE LICENSE APPLIED FOR; AND 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 REGULA-
TIONS, AND THE CIVIL RIGHTS SECTIONS THEREOF.
FURTHER, I AGREE TO NOTIFY THIS COMMISSION WITHIN 30 WORKING DAYS OF CHANGES IN ANY OF THE ABOVE INFORMATION.