NEW RENEWAL NO.
CITY OF LOCKPORT, ILLINOIS
ANNUAL FEE $300.00
PLEASE TYPE OR
HAND PRINT
APPLICATION FOR TASTING AND/OR SAMPLING PRIVILEGE
FOR CLASS H-1 OR H-2 LICENSEE
1. Applicant's Name;
2. Name under which business is to be conducted:
Address:
Business Phone No.:
3. Does Applicant presently possess license?:
Class of License: License No.:
Date of Expiration of License:
4. Description of area of premises to be used for Tasting and/or Sampling (Please attach sketch showing location):
5. Employee authorized to supervise said area (must be 21 years or older):
Name: Social Security No:
Date of Birth: Phone No.:
Address:
6. Supervising Agent or Manager:
Name: Social Security No:
Date of Birth: Phone No.:
Address:
7. Three-consecutive-day period for the Tasting and/or Sampling:
8. This is the request this year for Tasting and/or Sampling.
9. If the entity applying is not licensed by the City, then proof of registration with the State Liquor Commissioner is required to be attached.
10. Has annual fee of $300.00 been paid: Yes No
Applicant hereby acknowledges receipt of a copy of Ordinance No. 03-422 of the City of Lockport relating to the tasting or sampling of alcoholic beverages.
Dated at City of Lockport, Illinois, , 20
NAME OF CORPORATION
CORPORATE SEAL
SIGNATURE OF PRESIDENT
I hereby authorize said Tasting and/or Sampling to take place on
City of Lockport Liquor Commissioner
Date