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: Date Issued: (For MLCC use only) APPLICATION FOR BEER AND WINE CONSUMER SAMPLING EVENT PERMIT [Authorized by MCL 436.1537] GENERAL INSTRUCTIONS • A Beer and Wine Consumer Sampling Event License only applies to an Outstate Seller of Beer, Outstate Seller of Wine, Wine Maker,Micro Brewer, Brewer, Broker or a Specially Designated Merchant (not holding a license for on-premises consumption at the same address). • To be considered for a license you must sign the completed application. Return the application and a check payable to the State ofMichigan for the $70.00 inspection fee to the address at the top of this form. MAKE A COPY OF THIS APPLICATION FOR YOUR FILE. • You must obtain MLCC approval and receive your Consumer Sampling Event Permit document prior to conducting beer and wine consumer samplings. The MLCC must be notified at least 10 days prior to conducting beer and wine consumer sampling events. PART 1. APPLICANT INFORMATION 1. Check type of business: Limited Liability Company Corporation Partnership Individual 2. Full name of Limited Liability Company, Corporation, Partnership or Individual: 3. D.B.A. (Business Name and not Trade Names): 4. Street Address: 5. City: 6. State: 7. Zip Code: 8. Enter your license number or Vendor Code Number: 9. Business Telephone Number: Mobile Telephone Number: 10. Email Address: PART 2 ALL PARTNERS AND GENERAL PARTNERS OF LIMITED PARTNERSHIPS MUST SIGN THE CONTRACT FOR LICENSE. AUTHORIZED CORPORATE OFFICERS OR AUTHORIZED MEMBERS OR MANAGERS OF THE LIMITED LIABILITY COMPANY MUST SIGN THE CONTRACT FOR LICENSE. • I agree to abide by all provisions of the Michigan Liquor Control Code (P.A. 58 of 1998) and all the rules of the MLCC. • I authorize the MLCC to investigate records of this business to determine license qualifications. • I swear that all the answers on this application are true, that the applicant is the sole owner of the business and that submitting false or incomplete information is cause for denial of the license and is a violation of the Michigan Liquor Control Code of 1998. I swear that the hereinbefore described applicant is a bona fide company with sufficient financial resources to comply with the proof of financial responsibility requirements of the Michigan Liquor Control Code of 1998. • TITLE ADDRESS PRINT NAME X SIGNATURE OF APPLICANT LC-MW-1002 06/2014 Authority: MCL 436.1537 Completion: Mandatory Penalty: No License 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