Free IL-ELF Application - Illinois

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IL-ELF Application

This space for use by Secretary of State.

Fax completed form to: Secretary of State Department of Business Services 217-558-0076 (fax) www.cyberdriveillinois.com

You must complete this form to participate in the IL-ELF program. New Application Update _______________________
IL-ELF Number

1. Applicant/Firm Name ________________________________________________________________________________________ 2. Address ____________________________________________________________________________________________________
Street

______________________________________________________________________________________________________________
City, State, ZIP Code

3. Phone Number ______________________________________________________________________________________________ 4. Fax Number (required) ________________________________________________________________________________________ 5. Contact Person _____________________________________________________________________________________________ 6. E-mail Address __________________________________________ Phone Number _____________________________________ 7. Method of Payment (Select Electronic Fund Transfer or Credit Card) Electronic Fund Transfer: __ Checking Account __ Savings Account Routing Number ___________________________________ Account Number ___________________________________ Credit Card: __ Visa __ Discover __ Mastercard __ American Express Card Number _____________________________________________ Expiration Date ________________________________ Name on Card ___________________________________________________________________________________________ Cardholder's Billing Address ________________________________________________________________________________
Street

_________________________________________________________________________________________________________
City, State, ZIP Code

Printed by authority of the State of Illinois. C-328.1 -- web -- February 2006