Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) Constitution Hall, 525 W. Allegan, Lansing, MI 48933 Mailing Address: PO Box 30005, Lansing, MI 48909 Toll Free (866) 813-0011 · www.michigan.gov/lcc Business ID: Request ID: (For MLCC use only) Affidavit Relative to Racial Discrimination INSTRUCTIONS: Complete and return the original copy of this affidavit to the Commission. Name of Club: ________________________________________________________________ Address: ___________________________________________ County: __________________ I hereby certify that there are no racial disqualifications for membership or guest privileges contained in the charter, constitution, franchises, by-laws, membership application or related documents under which this club is currently operating. WARNING Section 1003 of the Michigan Liquor Control Code reads as follows: "FALSE AND FRAUDULENT STATEMENT. A PERSON WHO MAKES A FALSE OR FRAUDULENT STATEMENT TO THE COMMISSION, ORALLY OR IN WRITING, FOR THE PURPOSE OF INDUCING THE COMMISSION TO ACT OR REFRAIN FROM TAKING ACTION OR FOR THE PURPOSE OF ENABLING OR ASSISTING A PERSON TO EVADE THE PROVISIONS OF THIS ACT IS GUILTY OF A VIOLATION OF THIS ACT AND IS PUNISHABLE IN THE MANNER PROVIDED FOR IN SECTION 909. Signed ________________________________ Position Held ___________________________ Subscribed and sworn to before me, this _______ day of ________ A.D., 20 ____. ________________________________ (Notary Public) ______________, County, Michigan. My commission expires _____________. LC-1178 Rev. 06/14 AUTHORITY: MAC R436.1127 COMPLETION: Mandatory PENALTY: Non issuance of Permit LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. American LegalNet, Inc. www.FormsWorkFlow.com