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Dealer License Renewal Application Form

2. Business Information *

   Provide local business & corporate information

   1. Incorporated- Secretary of State
   2. Sole Proprietor- County
3. Corporate Name/ Sole Propietor*

4. Assumed Business Name/DBA*

5. Business License Renewal No.*

   This number is provided to you in your renewal form.

7. Preffered Mailing Address*

   1. Business Address
   2. Corporate Address

8. FEIN Number

9. IBT No./Retailer's Occupational Tax No.

11. Business Address*

12. Phone Number *

14. City*

15. State*

16. Zip Code*

18. Corporate Address

19. Phone Number

21. City

22. State

23. Zip Code

25. Ownership – Principals, Sole Owners, Shareholders, Partners, etc.
    .

    .

26. Addtional Information

    If you have additional owners, please attach a listing.

28. 1. Business Owner*

29. Email Address*

31. Address*

33. City*

34. State*

35. Zip Code*

37. Phone Number*

38. Cell Number*

40. 2. Business Owner

41. Email Address

43. Address

45. City

46. State

47. Zip Code

49. Phone Number

50. Cell Number

52. Employees
    All new employees are required to submit to a history and background check and be approved by the Clerk's Office. Please call 630-823-5602 to make an appointment for fingerprinting.

    All new employees are required to submit to a history and background check and be approved by the Clerk's Office. Please call 630-823-5602 to make an appointment for fingerprinting.

53. Additional Information

    If you have additional employees, please attach a listing.

55. 1. Name*

56. Title*

57. Age*

58. Start Date*

60. 2. Name*

61. Title*

62. Phone Number*

63. Start Date*

65. Property Ownership
    Building Owner

    Building Owner

67. Building Owner*

68. Email Address

70. Address

72. City

73. State

74. Zip Code

76. Phone Number*

77. Cell Number

79. Execute*

    1. I agree

    By selecting I agree option below you are giving your electronic signature.

80. No False statements
    Your submission of this form certifies that the information provided is true and correct.

    Your submission of this form certifies that the information provided is true and correct.

82. First Name*

    Information for individual completing this form.

83. Title*

85. Phone Number*

86. Email Address*

Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit Submit and Print

* indicates a required field