Savanna Illinois Forms
"Pride, Integrity & Dedication"

CITY OF SAVANNA APPLICATION FOR RETAIL LIQUOR LICENSE

CORPORATION
CLASS OF LICENSE APPLIED FOR: _____________________________

TO: LIQUOR CONTROL COMMISSION, SAVANNA, IL 61074

CORPORATION NAME:
MAILING ADDRESS:
CITY:  
STATE, ZIP:  
EMAIL:
TELEPHONE NUMBER:
DATE INCORPORATED:  
WHERE INCORPORATED:
CORP. PURPOSE:
LIST OFFICER AND DIRECTORS, ADDRESSES, DATES OF BIRTH, SOCIAL SECURITY
NUMBERS AND PERCENT OF STOCK OWNED. IDENTIFY BY NAME AND ADDRESS ANY
INDIVIDUAL OTHER THAN AN OFFICER OR DIRECTOR WHO OWNS A MAJORITY STOCK
INTEREST IN THE CORPORATION.
NAME, TITLE   
ADDRESS
DATE OF BIRTH
SOCIAL SEC NO. % STOCK
NAME, TITLE   
ADDRESS
DATE OF BIRTH
SOCIAL SEC NO. % STOCK
NAME, TITLE   
ADDRESS
DATE OF BIRTH
SOCIAL SEC NO. % STOCK
ADDITIONAL NAMES AND RELEVANT INFORMATION:
 
1.) NAME AND ADDRESS FOR WHICH LICENSE IS SOUGHT:
NAME:
ADDRESS: , Savanna, Illinois 61074
ARE THESE PREMISES OWNED BY THE APPLICANT? YES NO
IF LEASED, STATE TERM THEREOF:
2.) DESCRIBE YOUR PRESENT BUSINESS FOR WHICH LICENSE IS SOUGHT:
3.) ESTIMATE CURRENT NON-LIQUOR INVENTORY: $
      ESTIMATE CURRENT LIQUOR INVENTORY: $
4.) HAS THIS COMPANY MADE SIMILAR APPLICATION FOR THIS CLASSIFICATION AT A LOCATION DIFFERENT FROM THAT DESCRIBED IN #2? YES NO
IF YES, WHAT DISPOSITION RESULTED?
5.) WILL THE BUSINESS BE CONDUCTED BY A MANAGER OR AGENT? YES NO
NAME OF MANAGER OR AGENT:
RESIDENCE ADDRESS:
RESIDENCE CITY, STATE, ZIP:
SOCIAL SECURITY NUMBER:
DATE OF BIRTH:
6.) HAVE ANY OF THE OFFICERS, DIRECTORS, MAJORITY STOCKHOLDERS, MANAGERS OR AGENTS EVER BEEN CONVICTED OF A FELONY? YES NO
A MISDEMEANOR? YES NO
IF "YES", GIVE DATE, STATE OFFENSE AND DISPOSITION:
7.) ARE ALL OFFICERS, DIRECTORS, MAJORITY STOCKHOLDERS, MANAGERS AND AGENTS CITIZENS OF THE UNITED STATES? YES NO
8.) HAS THE APPLYING OFFICER, MANAGER, OR AGENT OF THIS CORPORATION READ TITLE 3 CHAPTER 7 OF THE SAVANNA MUNICIPAL CODE AND AGREE TO ABIDE BY IT?
YES NO
9.) DOES APPLYING OFFICER, MANAGER OR AGENT OF THIS CORPORATION KNOW OF ANY REASON WHY (name of coporation) IS NOT QUALIFIED TO HOLD THE LICENSE UNDER THE LAWS OF THE STATE OF ILLINOIS AND THE ORDINANCES OF THE CITY OF SAVANNA? YES NO
10.) HAS ANY PREVIOUS LIQUOR LICENSE BEEN ISSUED BY THE FEDERAL GOVERNMENT OR ANY STATE OR SUBDIVISION THEREOF, OF THIS COMPANY OR ANY OF ITS OFFICERS, DIRECTORS, SHAREHOLDERS, MANAGERS OR AGENTS AS INDIVIDUALS, PARTNERSHIP OR COPORATE STOCKHOLDERS BEEN REVOKED?
YES NO
11.) PLEASE LIST THE FOLLOWING, IF APPLICABLE:
       A.) FEDERAL TAX ID #:              
       B.) STATE OF ILLINOIS TAX #:   
       C.) STATE OF ILLINOIS LIQUOR LICENSE #:   
12.) ATTACH CURRENT COPY OF DRAM SHOP INSURANCE CERTIFICATE (please submit this either electronically [coming soon] or at City Hall, 101 Main St., Savanna, Il 61074)
State of Illinois       )
                                    SS.
Carroll County       )
 
I (or we) swear (or affirm) that I (or we) will not vioate any of the ordinances of the City of Savanna or the laws of the State of Illinois or the laws of the United States of America, in the conduct of the place of business described herein and that the statements cotained in this application are true and correct to the best of my (our) knowledge and belief.

 


__________________________________________________
Signature of Applicant
 
Subscribed and Sworn to before me this ________ day of _______________, 2______.

 


__________________________________________________
Notary Public
 
License Approved this ________ day of ________________, 2______.
 
By _____________________________________________________
Mayor of Savanna
 
            

Authorized by City Official Savanna, Illinois