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2. Palatine Employee BASSET Registration

   For all liquor establishment employees who are not managers or assistant managers, please complete this form.

4. Employee First Name*
5. Employee Last Name*
7. Establishment Name*
   -- Select One --Agio Italian BistroAldiAlley 64 Bar & GrillAmerican Legion Post 690American Tier 1 HockeyAmerican Ukranian Youth Association of PalatineAnnie's Restaurant & Pancake HouseArmanneti's Liquor Asahi Japanese RestaurantBacci Pizzeria Bendita Cocina Brandt's of PalatineButera Fruit MarketCafé 14 Chicago Culinary KitchenChiggy's Gyros Cook, Cork & ForkThe Cotillion CVS Pharmacy #5913D'Vine Wine and GiftsDonkey InnDurty Nellie's Emmett's Brewing Co.Extra Value LiquorsGarfield's BeverageIndie Foodie LoungeGator's Wing ShackGeorge's Wine & SpiritsGianni'sHeng Wing RestaurantHot Pockets Sports BarInverness Wine & SpiritsIslas VeracruzJ & J Liquor, IncJJ Twig's Pizza & PubLamplighter Inn Tavern & GrilleLaredo Plaza LiquorsLas Adas Liquor StoreLiquor LaneLos Arcos Taqueria MadCats Mariano's #8505Mexico Uno RestaurantMidtown Athletic Club -Tennis Corporation of AmericaMr. A's Liquor WorldOne Taco Dos TequilasOsco Drug - Plum Grove #3445 American Drug Stores LLCOsco Drug - Dundee Rd. #3474 American Drug Stores LLCP's & Q's Restaurant & LoungePalatine InnPalatine Park District DBA Palatine Hills Golf CoursePapa's LiquorPenalty Box (Soccer Enterprises)Pizza BellaPride of PalatineQuick LiquorRelish Catering KitchenRoccovino's @ Twin LakesSalsa StreetSalt Creek Sports Center Twin LakesSunrise Ramen & Sushi (Modun)Schnell's BrauhausSushi Para Japanese RestaurantSwej LiquorsT.J. O'Brien's Bar and GrillTacos Del NorteTap House GrillTaqueria MayaTarget Corporation - T-0753Twin Lakes LiquorsWalgreens - #07754 (805 E. Euclid)Walgreens - #03940 (375 E. Dundee)Walgreens - #04355 (12 N. NW Hwy.)WalmartWine Cellar Rep's BurgersRestaurante El Tio RamosCosmopolitan EventosAragvi
8. Employee's Date of Hire*
   Employee's Date of Hire
10. Employee's Address*

    Street, City, State, Zip

11. Employee Date of Birth*
    Employee Date of Birth
13. Employee's State of IL BASSET Number*
14. BASSET Expiration*
    BASSET Expiration
Leave This Blank:


16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field